NURSING: A WORLD VIEW
By
HUDA ABU-SAAD
A DISSERTATION PRESENTED TO THE GRADUATE COUNCIL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
1977 ACKNOWLEDGMENTS
I wish to express my deep appreciation to Professor
Margaret K. Morgan, chairman of my committee, . for her
patience, support, and continual encouragement. To the members of my committee. Professors Gordon D. Lawrence,
Amanda S. Baker, James W. Hensel, and Pauline H. Barton,
I am also grateful.
Appreciation is extended to Esther B. Jones, medical reference librarian, and her staff for their assistance in making available through Inter-library Loan many of the references used in this study.
Special gratitude is due to members of the P.E.O.
Sisterhood of the State of Florida for their interest and support, to the staff of the graduate school whose assis- tance went beyond the call of duty, and to Edna B. Larrick for her unlimited patience and skill in preparing the manuscript.
And finally, my love and appreciation are extended to my husband, Ernst Huijer, for his help in translating documents from different languages and for his encouragement and emotional support that made the undertaking possible.
ii TABLE OF CONTENTS Page
ACKNOWLEDGMENTS . . . ii
LIST OF FIGURES xi
LIST OF TABLES xii
ABSTRACT xiii
PART I
AN OVERVIEW 2
Introduction 2 Purpose of the Study 4 Definition of Nursing 5 Plan of the Study 8 Limitations of the Study 8 References 9
PART II
' ORIGINS OF THE PROFESSION . . . 11
The Pre-Christian Era 11 The Christian Era 14 The Dark Ages of Nursing 19 The Nightingale Reforms 22 The New World 2 7 References 30
PART III - EUROPE CHAPTER 1 ENGLAND 32
The International Council of Nurses .... 36 Nursing and World War I 36 The Royal College of Nursing 37 Training of Assistant Nurses 39 World War II 40 National Health Scheme 42
The Nurses ' Act 44 Nursing Education 45 Present Trends in Nursing Education .... 46 Nursing Services 49 References 51 Supplementary References 52
iii TABLE OF CONTENTS (Continued)
CHAPTER Page
2 IRELAND 53
Nursing Organization 56 Nursing Education 57 Domiciliary Nursing 57 The Bord Altranais 58 Trends in Nursing Education 59 National Health Services 60 References 62
3 GERMANY 63
The German Nurses' Association 64 Nursing Registration 65 Social Insurance in Germany 66 The National Federation of Nurses 67 Nursing Education 68 Collegiate Nurse Training 69 Present Concerns in German Nursing ... Education 70 References 72
4 HOLLAND 73
Early Training of Nurses 73 Early Nursing Organizations 75 Training Programs 77 Public Health Nursing 77 Professional Nursing 78 Future Trends 81 Health Care System 81
General Framework of Health Activities . . 83 References 85
5 FRANCE 87
The Nightingale System 88 Nursing Organization 90 Nursing Education 92 Postgraduate Education 94 References 98
6 ITALY 100
The Nightingale's Influence 100 The Italian Red Cross 102
Nursing Decrees and Nursing Programs . . . 103
Nursing Organization and Legislation . . . 104 Nursing Education 105 References 108 iv TABLE OF CONTENTS (Continued)
CHAPTER Page
7 GREECE ..... 110
Early Nursing in Greece 110 Nursing Education in Greece 113 Nursing Organization 115 Nursing Legislation 115 References 116
8 NORTHERN EUROPE 118
SInTEDEN 119
State Involvement 119 Nursing Association 120 The Swedish Federation 121 Nursing Education 122 Health Care in Sweden 127 Community Nursing in the Health Care Delivery System 129 References 132
9 YUGOSLAVIA 134
Early Nursing Practices 134 Development of Professional Nursing .... 135 Nursing Association 137 Nursing Education 137 References 141
10 RUSSIA 142
The Russian Revolution 143 Nursing Organization 146 Nursing Education 147 Nursing Service 150 Health Services 151 References 154
PART IV - AMERICA
11 CANADA 157
The Canadian Red Cross 158 Nursing Organizations .... 159 Nursing Education 161 Nursing Studies 164 Present Trends in Nursing Education .... 165 The Expanded Role of the Nurse 157 References 170
V TABLE OF CONTENTS (Continued)
CHAPTER Page 12 THE UNITED STATES OF AMERICA 172
Nursing Organizations 174 Nursing Education 176 Nursing Studies 180
! The Association of Collegiate Schools of Nursing 181 The Brown Report 182 Auxiliary Nursing 183 Associate Degree Nursing 183
! Restructuring Nursing Associations .... 184 Male i Nurses 185
^; Nursing Services 187 The Peace Corps 188 I
1: Nursing Trends 189 ^ Nursing Research 193 References 195
13 LATIN AMERICA 197
BRAZIL 203
The Development of Schools of Nursing . . . 203 Nursing at the University Level 205 Nursing Education ... 206
COLOMBIA 208
The Development of Schools of Nursing . . . 208 Nursing Education 210 Basic Nursing Education 211 Nursing Programs 212 Nursing Services 214
CUBA 216
Health Services 216 Nursing Education 217
MEXICO 218
Mexican Nurses' Association 219 References 220
vi TABLE OF CONTENTS (Continued)
CHAPTER Page PART V - ASIA
14 LEBANON 223
The Beginning of Modern Nursing 224 Nursing Education 226 Nursing Programs 227 Nursing Organization 230 Nursing Conditions 230 References 232
15 ISRAEL 233
The Beginning of Nursing Education .... 234 Nursing Education Today 236 Kibbutz Nursing 237 Nursing Organization 237 Primary Health Care 238 References 240
16 IRAN 241
The Development of Modern Nursing 241 Public Health Nursing 243 Nursing Division 243 Nursing Education 244 The Iranian Health Corps 246 References 248
17 INDIA 249
Nursing Developments 250 The Bhore Report 251 The Indian Nursing Council 252 Primary Health Care 253 Nursing Education 254 Nursing Associations .... 256 Public Health Nursing 257 International Aid 257 Nursing Service 259 References 260
18 JAPAN . 262
The Development of Modern Nursing 262 The National Nurses Association 263 Nursing Education 264 Advanced Nursing Education ... 266 Public Health Services 268 References 270 vii TABLE OF CONTENTS (Continued)
CHAPTER Page 19 CHINA 271
The Beginning of Modern Nursing 271 Nursing Developments 272 Health Care in Communist China 274 Health Education 275 The Health Care System 279 References 280
20 TAIWAN 282
Developments in the Health Field 282 Nursing Education 283
Midwifery in Taiwan . 286 Health Services in Taiwan 287 References 290
PART VI - AFRICA
21 SOUTH AFRICA 292
Early Nursing Developments 292 Nursing Organizations 293 Nursing Education 294 Bantu Nurses 296 Trends in Nursing Education 297 References 300
22 NIGERIA 301
Development of Modem Nursing 301 Nursing Education 302 Nurse Training Today 306 References 309
23 MOROCCO 309
Nursing Education 309 References 312
24 GHANA 313
Early Nursing Developments 313 Nursing Education 314 Nursing Legislation, 314 Health Services 315
Nursing Personnel and Their Training . . . 316 Trends in Nursing 317 References 318 viii TABLE OF CONTENTS (Continued)
CHAPTER Page 25 EGYPT 319
The Hakima School 319 The Beginning of Modern Nursing 321 Nursing Education 322 References 323
26 RHODESIA 324
Nursing Education 324 Advanced Nursing Education 325 References 327
2 7 ALGERIA 328
Health Education and Services 329 References ..... 331
28 ETHIOPIA 332
Modern Nursing in Ethiopia 332 References 334
PART VII
AUSTRALIA 336
Nursing Organizations 337 District Nursing 338
Nursing Education . 339
Colleges of Advanced Nursing Education . . 342 Goals in Nursing Education 343 The Role of the Nurse in Australia .... 344 Health Services in Australia 346 References 349
PART VIII
NEW ZEALAND 351
Government Regulations 352 Nursing Organizations 353 Nursing Council of New Zealand 354 Nursing Education 355 Change in Nursing Education 358 Health Services in New Zealand 361 References 364
ix TABLE OF CONTENTS (Continued)
Page PART IX
NURSING IN THE .FUTURE 366
Nursing Practice 366 Nursing Education 368 World Health and Nursing 370 Ethical Concepts in Nursing 372 References 374
PART X
SUMMARY: NURSING FROM ANCIENT TO
MODERN TIMES . . 376
BIBLIOGRAPHY 394
BIOGRAPHICAL SKETCH 419
X LIST OF FIGURES
Figure Page 80 1 Educational System in the Netherlands . .
.2 Auxiliary Nursing Personnel 126
3 Nursing Education in Yugoslavia 139
4 Nursing Services in Colombia 215
5 Nursing Education in Japan 267
6 Levels of Health Facilities in China . . 279
7 Development of Modern Nursing (Map) . . 378
xi LIST OF TABLES
Table Page 1 Nursing Education in Taiwan 285
2 Levels of Nursing Education in New Zealand 360
3 Nursing Registration and Organization . . 380
4 Levels of Nursing Education in the World 382
5 Primary Health Care Workers 393
xii Abstract of Dissertation Presented to the Graduate Council of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy
NURSING: A WORLD VIEW
By
Huda Abu-Saad
August 1977
Chairman: Margaret K. Morgan Major Department: Curriculum and Instruction
A world view of nursing that can be employed in the
international orientation of nurses is long overdue. Nurses
are demanding a wider knowledge of health conditions, educa-
tional systems, and nursing practices throughout the world.
This study examines the stages of development of the nursing
profession and the different roles that nurses take through-
out the world.
Thirty-three countries are included in this study;
namely, England, Ireland, Germany, Holland, France, Italy,
Greece, Northern Europe, Yugoslavia, Russia, Canada, the
United States of America, Brazil, Colombia, Cuba, Mexico,
Lebanon, Israel, Iran, India, Japan, China, Taiwan, South
Africa, Ghana, Nigeria, Rhodesia, Egypt, Morocco, Algeria,
Ethiopia, Australia, and New Zealand. For each of these countries the development of nursing as a profession is traced and the status of nursing education and nursing practice explained.
xiii Information was gained from the ministries of health of the respective countries, the World Health Organization, and the International Council of Nurses. Besides English references, articles in French, Dutch, German, Italian, Arabic,
Spanish, and Greek were used.
The study is divided into nine parts: Part I gives an overview; Part II traces the origins of the profession;
Parts III through VIII discuss nursing in Europe, America,
Asia, Africa, Australia, and New Zealand; Part IX predicts the future of nursing; and Part X summarizes nursing from early to present times and uses tables and illustrations to bring out worldwide movements that have contributed to the development of nursing such as the spread of the modern nursing system, wars and political systems, the feminist movement, the social structure of societies, the contribu- tions of international organizations such as the Red Cross and the World Health Organization, and the trend for higher education for nurses.
This study may be used by nurses, nurse educators, student nurses, scholars in and outside nursing, and others interested in the availability of health manpower throughout the world.
xiv PART I
AN OVERVIEW AN OVERVIEW
Introduction
The increasing complexity of life, the specialization
of knowledge, the gap between developed and developing soci-
eties, and concern over the health conditions throughout the
world, all point to the importance of communication and under-
standing among people, countries, and cultures. The growth
of bureaucracy and collectivization and the impact of this
change on the depersonalization of individual life has also
heightened the need for better communication among people.
The increased need for international education is an obvious result.
Present emphasis on international education relates
to an increasing interest in comparative education. Inter- national education is mainly an analysis of cross-cultural
educational influences and the impact nations have on one
another. Development education^ on the other hand, focuses on programs that describe the national educational planning within the political, economic, social, and cultural milieus of the different countries. Both terms — international edu- cation and development education— are encompassed in the term comparative education^ contributing directly or indi- rectly to the analysis and interpretation of educational —
3
practices and policies in the various cultures and countries
in the world.
As a result, the need for a world view of nursing
grows as nurses, as well as other members of the health pro-
fessions, become increasingly conscious of their interna-
tional role. In addition to a good scientific and technical
preparation, nurses are demanding that their education
include a wider knowledge of health conditions, facilities,
and systems of public health and nursing in other countries.
Such a broad view helps nurses to put into perspective the
various health systems and defines the stages of development
of their educational institutions, leading to a better appre-
ciation of the role of nurses in the world.
To understand nursing developments requires a study
of the international movement that includes a variety of nursing practices and provides a basis for a worldwide coop-
eration and friendship among nurses. Ironically, although
each country seems to illustrate the past or the future of
some other country, enlarges upon and acts out some step in
the progress of another, nurses usually find much they can
share with one another.
With such an international orientation, all aspects
of nursing — length and type of training, hours of duty,
living accommodations, legislation and licensure, quality
and extent of communication between nurse and physician become more understandable when examined country by country 4
until the various lands appear not as separate countries, but as different stages of or approaches to the solutions of a single problem: the providing of nursing care for the world.
Purpose of the Study
This study relates the story of nursing and the development of the profession to present nursing practices.
With an emphasis on the international orientation of nursing and a multicultural approach to education, nurses are recog- nizing the need to broaden their views of the profession by study and through travel beyond their national boundaries.
The growing interest in the international health movement encourages professional nurses to participate in such pro-
grams .
These considerations have led to this study. It is intended to orient the reader to past and present of nursing and trends for the future worldwide. Nurses, nurse educators, student nurses, scholars in and outside nursing, and others concerned with the availability of health manpower, can put the profession of nursing into perspective best by examining the phenomenon of nursing as it has evolved through history.
Only through such an understanding can one appreciate the close ties that exist in the profession and in education for the profession of nursing. 5
The writer hopes that at the end of this study, the reader will be able to
(1) Trace the development of modern nursing in each of several countries throughout the world.
(2) Compare and contrast nursing practices in several countries.
(3) Identify contributions of specific persons to the development of the profession.
(4) Show how general social conditions, especially those affecting the status of women, influenced the development and growth of the profession.
(5) Compare present standards of nursing education in various countries.
(6) Describe the role of the nurse in the health care delivery system of the world.
Definition of Nursing
The word nursing is derived from the same Latin root as nurture. Among ancient civilizations, nursing was never a special service but an integral part of the care given to the young, the old, the helpless, the sick, or the injured.
Through the ages, nursing has been associated with assis- tance to people in trouble.
Nursing as defined by Lesnik and Anderson is
. . . the performance of any service (1) rendered pursuant to a consensual agreement, (2) requiring the application of principles based upon the biologic, physical, and social sciences in the supervision of a patient involving (3) the observation of symptoms and reactions, (4) the accurate recordation of facts, (5) the fulfillment of the legal orders of a duly licenced physician concerning treatments and medica- tions with an understanding of cause and effect, (6) the accurate application of procedures and 6
techniques with an understanding of cause and effect, and (7) the additional safeguarding of the physical and mental care of the patient by the employment of
any nonremedial means, including but not limiting , the health direction and the education of the patient.
This definition came about as scientific discoveries
progressed, making the practice of medicine more complex and
putting pressure on nurses to assume more responsibility.
Out of this change in the concept of care of the sick has
emerged the professional nurse with the rights and privi-
leges accorded persons in other professions.
Building on the Lesnik and Anderson definition, the
Board of Directors of the American Nurses' Association in
1955 formulated a definition of professional nursing:
The practice of professional nursing means the per- formance for compensation of any act in the observance, care, and counsel of the ill, injured, or infirm, or in the maintenance of health or prevention of illness of others, or in the supervision and teaching of other personnel, or the administration of medications and treatments as prescribed by a physician or a dentist; requiring substantial specialized judgment and skill based on knowledge and application of the principles of biologic, physical, and social science. The fore- going shall not be deemed to include acts of diagnosis and prescription of therapeutic and corrective mea- 1 sures .
With the introduction of the term nurse-practitioner,
the definition of nursing which portrays the concepts inher- ent in the term focuses on the ability of the nurse to
. . , assess the health status of individuals and families through health and medical history taking physical examination, and defining of health and developmental problems; institute and provide contin- uity of health care to clients (patients) , work with the client to ensure understanding of and compliance with 2
7
the therapeutic regimen within established protocols, and recognize when to refer the client to a physician or other health care provider; provide instruction and counseling to individuals, families, and groups in the areas of health promotion and maintenance, including involving such person in the planning for health care; and work in collaboration with other health care providers and agencies to provide, and where appro- priate to coordinate, services to individuals and families .
The above statements define nursing in the United
States; they do not represent an international definition.
The definition of nurse adopted by the International Council
of Nursing in 1975, has been used as a membership criterion
for ICN and is also an internationally acceptable definition
of the scope of nursing practice. The definition states that
A nurse is a person who has completed a program of basic nursing education and is qualified and author- ized in her/his country to practice nursing. Basic nursing education is a formally recognized program of study which provides a broad and sound foundation for the practice of nursing and for postbasic education which develops specific competency. At the first level, the educational program prepares the nurse, through study of behavioral, life and nursing sciences and clin- ical experience, for effective practice and direction of nursing care, and for the leadership role. The first level nurse is responsible for planning, providing, and evaluating nursing care in all settings for the promo- tion of health, prevention of illness, care of the sick and rehabilitation; and functions as a member of the health team. In countries with more than one level of nursing personnel, the second level program prepares the nurse, through study of nursing theory and clinical practice, to give nursing care in cooperation with and under the supervision of a first level nurse.
The International Council of Nurses hopes that the
international definition of nurse will influence in years to
come not only curricula of nursing schools throughout the world, but the attitude of governments and other health pro- fessional groups as well. .
8
Plan of the Study
The various chapters of this study trace the nursing movement through history and over large parts of the globe by historical development, and through nursing organization, education, and the nurse's role in health care. Special attention is given to countries that took an active role in developing nursing as a self-governing profession, and to the general state of nursing in the various countries.
Parts I and II give an overview and examine the origins of the profession. Six other parts include develop- ments in Europe, America, Asia, Africa, Australia, and New
Zealand. Part IX predicts directions in which nursing may move. The last part summarizes nursing in early and present times
The investigator desires that the touching and often heroic history of nursing should be presented in its own context. Toward this goal she has researched references in
English, Spanish, Dutch, German, Italian, French, Arabic, and Greek. Also, for a clearer picture of present nursing practices, the writer contacted the Ministries of Health in the respective countries, the World Health Organization, and the International Council of Nurses for current infor- mation.
Limitations of the Study
Only those countries are included that, based on the resources available to the writer, have contributed to the development of nursing.
I
..i 9
Only those historical events having a direct influ- ence on the development of nursing are included.
Material in Part II was extracted from secondary resources; the writer cannot attest to its validity.
References
1 ANA Board approves a definition of nursing practice. -American Journal of Nursing^ 1955^ 55^ 1474 .
2 Capell, P. and Case, D. Ambulatory care manual for nurse practitioners. Philadelphia: J.B. Lippincott Co., 1976 .
3 ICN adopts definition of "nurse." International Nursing Review, 1915, 22(6), 184.
4 Lesnik, M. and Anders.on, B. Legal aspects of nursing. Philadelphia: J.B. Lippincott Co., 1947. PART II
ORIGINS OF THE PROFESSION ORIGINS OF THE PROFESSION
The Pre-Christian Era
In a contemporary look at the history of nursing, great gaps appear. This probably results from the tendency of historians to neglect what is usual and commonplace.
Nursing — as differentiated from medicine — is not mentioned in accounts of ancient times. Undoubtedly at one time medicine and nursing were united. At all times throughout the world nursing and medicine have been parts of an existing culture, have been shaped by it, and in turn have helped to develop it.
The comparative study of nursing, like comparative studies of other aspects of those cultures, can be fascinating.
Thousands of years before the Christian era, the regions of Asia were the abodes of advanced civilizations.
The ancient Hindus believed that the prevention of disease was more important than the cure, and their medical works 3-28-9 contain innumerable rules of hygiene.
More details of nursing are found in the Hindu records than in any other ancient chronicles. Lesson IX of
Charaka-Samhita gives this exposition: "The physician, the drugs, the nurse, and the patient constitute an aggregate of four. Of what virtues each of these should be possessed, so
11 12
as to become causes for the cure of the disease should be
3 • 32 known." ' Thorough mastery of the scriptures, large expe- rience, cleverness, and purity were the principal qualities of a physician. The four qualifications of the attending nurse were knowledge of the manner in which drugs should be prepared and compounded for administration, cleverness, devo- tion to the patient waited upon, and purity. However, the patient, the nurse, and the drugs were regarded as objects 3 34-5 in the hands of the physician to achieve a cure.
King Asoka, who spread Buddhism three centuries before Christ, is said to have built institutions for the care of the sick, in which the attendants were asked to be gentle in the care of their patients, to give refreshing juice, medicine, and massage and to keep their own bodies 4:41 clean.T
Like India ancient Egyptians had an extensive knowledge of the arts, sciences, and medicine. The oldest medical records discovered and deciphered thus far appear to be Egyptian. Many diseases and surgical operations known today are described and classified, and more than seven hundred drugs of the vegetable, mineral, and animal kingdoms
3-50-2' are enumerated, in the Ebers Papyrun encyclopedia.
The position of woman in ancient Egypt was supposed to be good in comparison with her position in earlier days.
However, no mention of nurses or hospitals is made in medical books. That a nation that brought medicine, pharmacy, and 13
sanitation to so orderly and systematic a state should not
3-52 5 3 have; had a nursing class seems unreasonable. •^^~->->
As in Egypt the scanty records of Mesopotamia tell
us nothing about nursing as such or the presence of hospi-
tals during that period of history. The Legal Aspect of
Assyrian lore was given in the Code of Hammurabi, king of
Babylonia, about 2000 B.C. It showed an organization of
medical treatment and surgery with fixed fees and definite
penalties for failure to effect cures. The Assyrian Pharm-
acopoeia also was as embracing as that of the Egyptians. 2^11-6:7:20-1
The Jews learned much of their hygiene from the
Egyptians. Certain sanitary measures practiced by Egyptians were enforced by the Jews. The Mosaic Law gave directions
concerning matters of hygiene, such as rules of diet and
cleanliness and hours of work and rest. The Jews and the
Arabs were pioneers in preserving and even advancing medical knowledge during the period from the fall of Rome until the revival in ^ ^'^"^ Europe of ancient Greek and Roman learning . '
Like many older countries, Greece traces its medical art back to a mythical past of divine origin. The Asklepios myth, traced to thirteen centuries before Christ, depicts the medical and nursing arts present at that time. Hippocrates recognized nature and taught that disease was not the work of spirits, demons, or deities, but resulted from disobedience '67- to natural laws. 8 showed that the true art of the 14
physician is to assist nature in the cure. In his teaching,
Hippocrates spoke of the cleanliness of the bedclothes, of
using powder on moist skin, and of the cleaning of the mouth.
Except for the giving of drugs, the nursing care of the
patient was understood by the ancient Greeks. However, be-
cause of the silence of the records, real nursing by effi-
cient and educated women is assumed to have been practically
o . on _ 9 unknown in those days. "
The inhabitants of Rome benefited by the discoveries
of the Greeks but did not make original contributions to
scientific techniques. In nursing history, Rome's chief
importance consists in having originated hospitals for the
sick or wounded in the army. The great contribution of Rome 5 18- 19 to medicine is the hospital system. ' ~ Of nursing there
is no record, apart from the work of military orderlies in
the array. Probably in the homes of the rich nursing was done by slaves. The diffusion of medical knowledge accumulated in the Near East and Greece was important as a transition in the development of nursing.
The Christian Era
With the beginning of Christianity the history of nursing for the first time became continuous. Christ iden- tified the love of one's neighbor with the love of God. He stressed the care of the sick in such statements as: "I was sick and ye visited me." Illness among Christians immediately became an object of special attention. In like manner, 15
nursing was lifted to a plane of moral and religious obliga-
tion and became a respected occupation in which the most
unpleasant work was ennobled by a sense of devotion to a 6:76-8 great cause.
Most active in such services were the women of the new faith. Three classifications of women were recognized
as having special functions that dealt with the poor in the
early church: the deaconesses, the widows, and the virgins.
The deaconess carried secular as well as religious duties.
Many deaconesses were women of wealth and position. Probably the most famous of these ladies was Fabiola, who was viewed as the patron saint of early nursing. The widows, like the deaconesses, worked among the sick and the poor but apparently had less church work to perform. The virgins, on the other hand, were more concerned with church duties and religious exercises than with charitable work with the sick.^'^^
The order of deaconesses of the early Christian church may be well contemplated with affectionate respect as having laid the foundations of the nurses' calling and of all modern work of charity. " ~ Among women who started this calling for nursing were St. Fabiola, who nursed the poor while sharing their poverty; St. Marcella, who founded the first monastery for women in Rome, and St. Paula who devoted fortunes to the building of hospitals and inns for pilgrims on the way to Jerusalem. Probably no group of women ever associated with hospitals and nursing organizations 16
has surpassed these in intellectual powers and commanding
. , 5:72-3 force. of character.,
Little distinction was made in the early Christian
era between caring for the sick and ministering to the poor.
These activities are now shared between the professions of
nursing and social work but were linked in the past, for
they were seen by the church as acts of helplessness and
5 • 75 humility requiring attention and service.
Motives that led individuals into nursing were more
varied th an those of today. Nursing, with the dawn of
Christianity, took a high place among people as a penance
for sins and solace for unhappy lives. ' However, the
situation for some of the members of the group of exalted matrons whose independent positions and great wealth were
used to establish community life and to organize large foun-
dations for charity and nursing work. Roman matrons put
their energies in the founding of monasteries in which women might find, not only refuge and security, but also a place
to pursue intellectual studies or practical interests.
There they could work together to establish hospitals, prepare drugs, and attend to the needs of the sick and the 3: 135-6 poor.
With the rise of monasticism, medicine and nursing were taught as liberal sciences to nuns and monks who were the sole practitioners of medicine in that era. In nursing, the monks did the nursing in the men's wards and the nuns .
17
in the women's. This arrangement prevailed all over
Western Europe where nurses were in charge of entire hospi-
tals. Though it cannot be claimed that much progress was
made in the scentific aspects of medicine or of nursing,
undoubtedly humane care administered to the sick and the
needy was immensely advanced by the release of great love,
the feeling of brotherhood, and the religious zeal that found
expression in direct personal service to those in need.
Christianity also gave women an opportunity to practice their
own interests in contributing to hospital reform and char- itable works
The first religious order of men in the West was
that founded by St. Benedict and known as the Benedictines.
The rule of St. Benedict commanded that "... before and above all things, care must be taken to the sick that they "^'^^ be served in very truth as Christ is served. Benedic- tine monasteries spread throughout the western church and, wherever established, became of great value to local commu- nities. These monasteries were centers of learning up to the time when universities began to develop.
In about the twelfth century, a definite separation took place between establishments intended for sick persons only and those intended for the aged.^'-^^ Many religious orders emerged as a result with the main purpose of curing the sick. These orders fell into three groups: the military nursing orders that were the outgrowth of the Crusaders, 18
secular orders, and regular orders such as the Augustinian "^^"^ ^ ' Sisters of the H8tel-Dieu in Paris .
As the scale of warfare in the Middle Ages increased
and battles were fought in distant lands, the effects became
more deadly for disease was carried wherever armies were sent.
The Crusades are of special interest in this respect because
they constituted the founding of the military nursing orders.
The Knights of St. John, the Teutonic Knights, and the
Knights of St. Lazarus were known for their contributions to
military nursing and to the building of hospitals in differ- ent '"^^"^ parts of the world. ' The hospital service
imprinted a certain military form of organization and
discipline of which distinct traces are still seen.
The secular orders became active in the thirteenth century. They were not an innovation of this period, since fraternities seem to have existed and to have done nursing along with other work.^'^'^"^ Orders like the Franciscans, the Carmelites, the Dominicans and others were societies that originated outside rather than within the church. All secular orders were not devoted to nursing. However, among those which made it their main work was the order of the Holy
Ghost founded by Montpellier. This order is said to have controlled some 900 hospitals in Europe.
The Augustinian Sisters of the Hotel-Dieu of Paris were one of the famous regular orders and one of the oldest purely nursing orders of nuns. Sisters spent their life in 19
the wards and only went out of the hospital to do visiting 2-87 nursing. ' The literature contains little on the instruc-
tions the Sisters had for the improvement of nursing the
sick and to what degree their nursing differed from domestic
nursing.
The Dark Ages of Nursing
With the beginning of the sixteenth century the
medieval period in history ended and the modern period began.
The fmdamental outlook in Western Europe shifted from the
God-centered, supernatural point of view to a nature- centered
or naturalistic and secular point of view. The consequences
of this change were on the one hand the increased material
progress and invention, and, on the other, a destruction of
the spiritual lanity of western civilization.
The confiscation of church properties by Henry the
VIII of England involved the hospitals and naturally the
doctors and nurses therein. The abrupt change brought about
by the sudden closing of hospitals during the Reformation
period with the dissolution of monasteries brought with it a
disorganization in the state of nursing. The wealth taken
from the monastic orders was turned into institutions for
the education of men. Women who were taught by nuns in
convents were left out, and nurses for hospital services
were drawn from the illiterate . classes ' This reflected
the temper of the time and accounted for the marked loss of 20
interest in humane and charitable work that characterized
the preceding period.
The deterioration in hospital nursing brought about
by the Protestant revolt spread all over Europe. Physicians
were scarce and nurses trained to help them were not avail-
able, hence patients were regarded as only material for
experimentation. With the coming of the Reform period, many
of the humane Christian characteristics were lost. Women
were subjugated and deprived of education, which was thought
to be useless and disruptive to their character. Those who
did nursing were middle-aged women whose time was divided
among housework, laundry, scrubbing, and a pretense at nurs-
ing. Because of these andothei circumstances nursing entered 7-78 a stage referred to as the "dark ages of nursing." '
This picture was relieved by the courage and far-
sightedness of two men, St. Vincent de Paul in 1633, a
Catholic priest, and Pastor Fleidner in 1863, a Lutheran
minister. In 1630 St. Vincent de Paul inaugurated a plan for
instituting a society for Ladies of Charity to visit the
homes and assist the sick. The members were required to be
intelligent and refined young women interested in the poor
and the sick. St. Louise de Marillac became the first direc-
tor of the order. Hence, into this dark period of nursing
the zeal of the Sisters. of Charity became infectious and
attracted many young women whose work flourished and spread, eventually encircling the globe. They performed every work 21
of charity including nursing in hospitals and homes, teaching
in schools, taking charge of orphanages, and giving heroic
, . 7:83-4 service during wars.
The Sisters of Charity were instructed in reading,
writing and arithmetic. They formed classes among each other
to discuss and question the lecture given by the physician.
On graduation from the program, the Sisters were sent to
other parishes as visiting nurses. St. Vincent continued
counseling them not to overwork and not to take more than
eight nursing cases at a time, the number modern nurses were
• 7 ' RU also to find reasonable.
Almost two hundred years after St. Vincent
established the order of the Sisters of Charity, Pastor
Fleidner, influenced by the work of the deaconesses in
Holland and inspired by the Sisters of Charity, established
the Kaiserwerth institution. Deaconesses were prepared for
many kinds of services in this order. They were taught
nursing, teaching, the management of children and convales-
cents, including work and play activities and parish visiting
and religious theory, so that they could read and interpret
the scriptures The Kaiserwerth Deaconesses, like the
Sisters of Charity, brought reform into the hospital and com-
munity nursing. Patients were treated with love and kindness
and were seen as individuals, not as cases for experimentation.
Medicine, contrary to nursing, saw considerable development during the Renaissance. The study of anatomy and 22
physiology progressed as physicians attempted to find inter-
nal causes of disease. Obstetrics and gynecology emerged as
areas of study in medical practice. Surgery, however, was
regarded as inferior to medicine, resulting in a scarcity of
surgeons at that time. During that period such names emerged
as Paracelsus, the founder of chemical pharmacology. Pare',
surgeon and inventor of many surgical instruments, Vesalius,
founder of the science of anatomy, and Harvey, discoverer
of the circulatory system (with the exception of capillary 2 ' 130-2
anastomosis) .
The Renaissance, which introduced the arts and
culture, benefited medicine by renewing interest in the natural sciences. However, it hurt society by giving it a
set of false values. Pleasure, leisure, and wealth were placed above work, service, and devotion. The Reformation
split a united Christendom, confiscating church properties and driving out the religious and leaving the poor and the sick with no one to care for them. While England had the worst health system at that time, it was from England that
the world received a new system which improved hospitals, sanitation, and reinstated nursing '^^^"^
The Nightingale Reforms
Florence Nightingale, a leader and reformer in nursing, was born May 12, 1820, in Florence, Italy, of a well-to-do English family. She was intellectually gifted and a precocious child with a mind of her own. She was 23
concerned from childhood with the needs of sick neighbors and members of her own family and was drawn to nursing by a strong desire to care for the sick. She wanted to establish a sort of protestant sisterhood like the deacon- ess order, in which educated women would devote their lives to nursing. Her family, opposing her plan, allowed her to visit at Kaiserwerth where she was granted later a three- month training period under Pastor Fleidner and his wife.
There she realized her dream of practical instruction in nursing. After that, she worked for some time with the
Sisters of Charity in Paris where she observed the French
r: 1:167-8 art^ of surgery.
Having convinced her family of her desire to become a nurse, she took a position in charge of a private nursing home. Not long after the Crimean War broke out in 1854,
Florence Nightingale was appointed superintendent of the
Female Nursing Establishment of the English General Hospi- tal in Turkey. With the help of 38 other nurses, she over- threw the long-established method of organizing and admin- istering the medical service of the British army. The nurs- ing and sanitary reforms she initiated reduced the death rate from more than 400 per 1000 patients to 22 per 1000— a rate never before known in the army even in peacetime ''"'^^
The soldiers loved her and felt reassured when she was around
Her night rounds in the hospital units gave her the title of the Lady of the Lamp. 24
Florence Nightingale's work in the Crimean War provided the basis for the modern organization of nursing
and its professionalization . It brought to public atten-
tion not only the need for adequate nursing in war, but that
for adequate nursing for all the sick. The fact that these needs could be met through the training of young women sur- prised people of the day. Florence Nightingale saw nursing as a part of a well-planned and efficiently carried out project for the health of civilians at home, men in the army, and natives of England's colonial possessions, then mainly
India, Australia, New Zealand, and large areas of Africa. '
Upon her return from the Crimean War, Florence
Nightingale's health did not permit her to direct in person the newly founded school of nursing. The responsibility was placed in the hands of a committee and St. Thomas's
Hospital was selected as a place to try the experiment. The new school was established amid hostile comment and crit- icism from the medical staff who were taking responsibility then in the training of the Sisters. In spite of individual doubt and disapproval, and with the encouragement of the more enlightened members of society, the Nightingale school opened
"'"^^ on June 15, " 1860 with 15 probationers . Most significant in this respect v/as the recognition of science as the supreme authority in the education of a nurse.
Students of St. Thomas's received a year of train- ing, which included instruction from the matron, the ward 25
"Sister" (head nurse) and the physicians. Next they had a
two-year hospital experience, during which some probationers were paid modest salaries while gaining experience under
supervision. Others, intended to fill higher positions later
had to pay their own tuition for the first year and received
a different kind of training the following two years. The
distinction between ordinary probationers and "lady nurses"
reflected British class consciousness. The former group was
drawn from the uneducated population while the latter con-
sisted of women of birth, breed, and education. This was hoped to establish public confidence and respect for the new nurses "'"''"^"^
In administering the school of nursing, Florence
Nightingale recognized two things: the necessity of compe- tent personnel, and the adequate endowment of the school to prevent the hospital from using students for noneduca- tional duties, two principles still strikingly important.
The school had a Motherhouse system in which a certain degree of control was retained over the nurses after grad- uation. Therefore, nurses were engaged through the school, which took the responsibility for the homes and institu- tions into which they were sent, as it did for the quality of nursing . "^"''^ service they gave '
In hospitals the Nightingale reform affected the matrons and sisters whose responsibilities, power, and dignity were greatly enlarged. Probationers and staff 26
nurses took the place of the old-style attendants, and ward
maids, who had been doing most of the nursing, were employed
for the domestic work. Night duty was started with a con-
tinuous, orderly system where graduate nurses took night
shifts on an alternating basis.
Not all the movements made in nursing during that
period are attributed to Florence Nightingale. Efforts in
other European countries on sanitary reform and medical
progress were also noted. The Nightingale influence,
however, was felt in most Protestant areas such as Holland,
the Scandinavian countries, and parts of Germany. In
Holland, a secular nursing order started in Amsterdam in
the 1880s and a Dutch Association for Sick Nursing was set
up in 1892.^'^^^ ^ On the continent, the Red Cross movement
grew, as did Nightingale's, out of sympathy for the suffer-
ings of sick and wounded soldiers observed by a Swiss,
Jean Henry Dunant. As a result, in 1863 by the "Convention
of Geneva," twelve governments founded the International
Red Cross Organization. Men and women volunteers were trained to give emergency service during wars . This led
later to the development of Red Cross Schools of Nursing and hospitals
In general, religious orientation continued to
prevail in Catholic lands, and secular nursing orders
became common in English-speaking countries. Both types of nursing flourished in Holland, Germany, and Scandinavia. 27
Red Cross institutions, spreading at an increasing rate
throughout the world, reflected whatever type of nursing ^ existed in a given country . " On the whole, the
standards of nursing rose throughout most parts of Europe between 1860-1900. Formal training became the trend and organized lay nursing picked up respect. This trend
involved extensive opportunities for women, who constituted
the majority of nursing students then. By the end of the nineteenth century, nursing was generally viewed as a woman's vocation.
The New World
European nursing standards took roots in other countries of the world. Latin America responded to French and Spanish institutions, India to the English, and Japan to general Western examples. The most conspicuous and wide- spread modification of the Nightingale system has been made in the United States and Canada and is referred to as the
"American System." As in Britain, nursing schools in the
United States were usually attached to the hospital. An exception was the role of the English matron whose place in
America was filled by the superintendent of nurses with responsibility for nurses in the hospital as well as the training school. Student nurses received theoretical instruc- tion which was, on the whole, broader than that provided by the Nightingale plan.^'^^^"^ ——
28
American nursing has had no one outstanding personal ity such as Florence Nightingale; nevertheless the movement fell into capable hands. The activities of three women
Lavina Dock, Isabel Hampton, and Adelaide Nutting, who founded the Nursing School at Johns Hopkins in 1889 —were remarkable at that time. From the beginning, these women sought to improve theoretical instruction as well as prac- tical training. The initiation of the American Journal of
Nursing in 1900 by Adelaide Nutting was another important step toward a professional status. The American Nurses'
Association and the National League for Nursing Education 7-122-3 later made the periodical their official organ.
Securing legal recognition for graduate nurses through registration was carried to distinguish between graduate and nongraduate personnel. This was desirable because a large number of people — trained or untrained were active in practicing nursing then. No attempt was made by the American Nurses' Association to limit the right to practice to those who passed State examinations. As a result standards for nursing theory and practice were set and state examining boards made up of graduate nurses were established.
The title, Registered Nurse (RN) was given to graduates of authorized institutions. Educational standards improved gradually to allow the graduate nurse to secure further education, which increased the horizons of those nurses v/ho 29
planned to become instructors. This movement set the stage
''"'^^ for university- level nursing outside hospital control
The accrediting of schools of nursing has been an essential means of improving programs in nursing education on all levels. The National Organization for Public Health
Nursing in 1920 was the first accrediting body within the profession of nursing. In 1933 the National League for
A- ' 2 9 2 Nursing inaugurated its accrediting program. ' The ulti- mate goal is to improve nursing service through the improve- ment of nursing education. Other specific nursing develop- ments in the United States will be covered in a separate section of this study. 30
References
1 Dolan, J. Goodnows history of nursing . Philadelphia: W.B. Saunders, 1968.
2 Frank, M.C. The historiaal development of nursing. Philadelphia: W.B. Saunders, 1953.
3 Nutting, M.A. and Dock, L.L. A history of nursing. New York: G.P. Putnam's Sons, 1910.
4 Sellew, G. and Ebel, E. A history of nursing (3rd ed.). St. Louis: C.V. Mosby, 1955.
5 Seymer, L. A general history of nursing . London: Faber and Faber Ltd., 1935.
6 Shryock, R. The history of nursing. Philadelphia: W.B. Saunders, 1959.
7 Stewart, I. and Austin, A. A history of nursing. New York: G.P. Putnam's Sons, 1962. PART III
EUROPE CHAPTER 1
ENGLAND
Florence Nightingale's demonstration of the possibil-
ities for nursing, followed by the success of other nurses, drew widespread attention to the possibilities of nursing as
a profession for women affording an opportunity for the
relief of suffering and service to humanity. Though British women in 1860 still suffered under some traditional handi- caps and restrictions, a few broke through the taboos by find ing careers in different forms of public service, most notice ably in nursing.
By 1900 the greater recognition of the value of skilled nursing had led to a greater demand for the services of nurses. Also the growing provision of skilled educated women ("Lady Nurses") to look after the poor, not only in the hospitals but also in their homes, did not go unnoticed. The urge among the upper classes to nurse the poor in the second half of the nineteenth century was accompanied by an urge to be attended by nurses when they themselves became •1,1:53
In 1859 Florence Nightingale helped William Rathbone to establish the first district nursing association in Liverpool. The three principles recommended by her and
32 1
33
adopted by the school were:
(1) district nurses should have special training for their work,
(2) they were not to give alms or material relief, and
(3) they must not interfere with the religious views of their patients . • 160-
The new philanthropic movement needed time to outgrow the old
concept that home visiting of the sick was a demonstration of religious charity.
In 1887, Queen Victoria's Jublilee Institute for Nurses was established to prepare nurses to work with the poor and the sick in their homes. A six-month course was offered to hospital- trained nurses on community work. Mid- wifery, which was considered by Florence Nightingate to be a separate vocation from nursing, created a problem to the Queen's nurses who were confronted by maternity patients dur- ing their home visits. This led to the establishment of the Midwifery School by the Queen's Institute which considered the trained midwives essential for better maternal and child ^^125-6 care.
Little attempt was made by the Nightingale school to train private nurses and, as a result, this branch of nursing never attained the same professional and social status in Britain as did hospital, district, and military nursing. In 1885, following the Public Health Act, the first indus- trial nurse, Phillis Flowerday, was employed by one of the factories in Britain . = 1^2 Also, Britain witnessed the .
34
school nursing movement which was started by the efforts of
Amy Hughes in 1892. In spite of the prevalence of training
schools, large numbers of untrained lay nurses and midwives
still practiced nursing from experience, and few criteria
v/ere available whereby the general public could judge their competence
To remedy this situation, a group of "lady nurses,"
prompted by feelings of insecurity about their own status,
banded together to introduce the first register of nurses.
This was done to bring about a fair distinction between the
trained and the untrained. The militant nurses wanted the
register to draw a line between those who were fitted to
practice as nurses and those who were not, raising the ques- tion of qualification. This issue was taken up by a central
body of nurses whose job was to decide which hospitals pro- vided adequate training and which did not. In addition, a
national examination was planned to ascertain whether each
individual trainee had benefited from the course of study. Only those who passed the examination were to be admitted to the register. ^2-22^"^
Contrary to Florence Nightingale's training, which stressed the concept that nursing is within the capacity of any girl, the militant lady-pupils saw nursing as an appren- ticeship, a period of trial, almost an initiation ritual, which tested who was fit to bear the title nurse. With these objectives in mind, Mrs. Bedford Fenwick formed the British Nurses' Association and with the help of her physician .
35
husband, secured a vote by the British Medical Association
approving the registration of nurses by act of Parliament. This brought Florence Nightingale's fighting spirit back for
she believed that State licencing would lower the standards of nursing. She associated professionalism with trade union-
ism, of which she disapproved. Her chief argument against the register and nurse registration was that character and morals were nonregistrable . Florence Nightingale's views
were influential, for many matrons in different hospitals
showed vigorous opposition to registration Such were the issues that lay beneath what nurses call "the thirty years war"— a battle for status conducted against
a background ^ = ^^"^ of snobbish, militant f eminism. In spite of all this, the lady nurses formed the British Nurses Asso- ciation with Ethel Fenwick as president. This was similar to a union of nurses made up of the elite of the profession. In 1893, to have means of expression, Ethel Fenwick assumed control and editorship of a small weekly paper called The tluvsing Record, and enlarged it in 1902 to become the British Journal of Nursing This journal rapidly became the foremost nursing journal in the world and the most complete record in existence of nursing affairs and progress in all countries
The British Nurses Association received a charter in 1893, the first given to professional women by a Queen. In 1894 the Matrons' Council of Great Britain was organized, which (at present) is represented by the Association of 36
Hospital Matrons. This grew into a powerful associati on
largely concerned with improvements in nursing education and organization.
The International Council of Nu rses
The International Council of Nurses (ICN) grew out
of a suggestion by Ethel Fenwick during the meeting of the
International Council of Women in 1899. This was supported
by nurses in the United States, Canada, Denmark, Holland, South Africa, New Zealand, and Australia x^ho attended the
conference. The aim of the International Council was
(1) to develop self-governing principles among nurses under nurse leadership, and
(2) to develop a profession that would raise ethical and social status of nurses.
Through professional congresses, the spirit of the ICN
permeated a progressive and liberal attitude and stressed individuality and diversity among its members. As a result, fellowships were created to support nursing groups in their
" struggle ""-^ for development .
Nursing and World War I World War I affected Britain tremendously. Nursing resources were drained to beyond the minimum requirements of civilian hospitals, with the army enrolling a large number of the trained nurses. ^^^^^ The Voluntary Aid Detachment (V.A.D.) grew out of an unprecedented need for nurses. This corps consisted of lay persons who received a short course of three to six months in first aid nursing. The staffs of civilian .
hospitals were depleted as nurses left their positions to care for sick and wounded soldiers. Military hospitals had approximately one trained nurse to sixteen patients and voluntary hospitals had one trained nurse to ninteeen 8:171-2 patients^. ,
The Royal College of Nursing
Not surprisingly, nurses became keenly concerned about developing an order in the nursing profession. Dame
Sarah Swift, the chief matron of the British Red Cross
Society, and the Honorable Arthur Stanley, Treasurer of
St. Thomas's Hospital, took the initiative to organize the nursing profession. As a result of many efforts, the new
College of Nursing came into existence in 1916. The objec- tives that formed the basis for its founding were:
(1) to promote better education and training of nurses and the advancement of nursing as a profession in all or any of its branches,
(2) to promote uniformity of curriculum,
(3) to recognize approved nursing schools,
(4) to make and maintain a register of nurses to whom certificates of proficiency or of train- ing and proficiency had been granted,
(5) to promote bills in Parliament for any cause associated with interests of the nursing pro- fession, protection, or recognition by the State. ^- 89-90
The fusion of the Royal British Nurses' Association and the College of Nursing came about as a result of a statement made by Princess Christian that such a fusion wou ^
38
be of great advantage to the nursing profession and to the
public at large. However, many leaders of the pioneer
organization in Britain attacked the College of Nursing
vigorously and the position was supported by many influen-
tial nurses from other countries. In spite of this, nurse
members in the College increased in number, assuming more
active leadership roles. Branches of nursing in other parts
of England were developed, offering refresher courses that
were then added to the program. The Nursing Times became the official organ of the College and later became a weekly ^^"^ ^ " professional j ournal .
The Royal College of Nursing, a national self-
governing organization, was founded in 1916 and combined lay and professional groups. One of its first activities was to push through the nurses' registration act.^"^^^ In addition to the general part of the register which was only open to
females, sections were included for males, for children's nursing, fever nursing, mental nursing, and mental deficiency nursing. After the Registration Act was passed by the Parlia- ment in the 1919, shortage of nurses was the main problem fac- ing the hospitals and the public. In 1930 the medical journal. Lancet, appointed a commission to look into the situation. Discipline in the nursing schools, which was unnecessarily severe, and the strict regulations, which were annoying to the public, were acknowledged as contributing to the short- age. Another difficulty was the conflict between the educa- ^ tional and . the practical aspects of the training " 39
The recommendation of the committee included better prospects for young women, the establishment of scholar-
ships, and increased salaries for graduate nurses. The
committee also suggested arrangements should be made for nurses to join the superannuity and the pension schemes.
Limited hours of work per day and better admission stan-
dards were among the many recommendations. The committee was hopeful that with such reforms the crisis could be over-
come and the supply of nurses would again be equal to the
demand. Nursing conditions improved, undoubtedly as a
'^'^ ^ . result of these recommendations '
Training of Assistant Nurses
Turning to other means of meeting the immediate shortage of nurses, the issue of bringing in assistant nurses arose. These nurses v/ere unqualified women who varied greatly in age, skill, experience, and ability to care for the sick. Many were ex-student nurses who had not completed their training or had failed to pass the examinations. Admission of this group of nurses to the Roll was not by examination but through two years training in an institution. The tide of the second World War brought the careful attention of the public to the status of the assistant nurses and their chance of existence as a separate entity in '-^^"^ the " nursing profession . AO
World War II
The outbreak of war in September, 1939, occurred at a critical time for the nursing profession. Civilian nurs- ing problems were especially complicated and difficult because of the high rate of casualties during that period.
Little distinction existed then between civilian and military nursing and hence many civilian nurses were assigned to nurse soldiers in the military hospitals. Early in the war the
Ministry of Health set up a Civilian Nursing Reserve which trained nurses not actively engaged in nursing, assistant nurses, and untrained volunteers. The Reserve came into being early in 1939, however, by 19A0, about 6,200 full-time
5-152-3' members were at work in hospitals.
A research committee's suggestion of a recruiting center and public relations department for nursing was taken up by King Edward's Hospital Fund for London. As a result, the Nursing Recruitment Center was opened in April
19A0, and was headquartered in offices adjoining the College
3 * 1 3 A- of Nursing. ' Advisement to prospective students and public relations were the main types of work that called for activities that would attract more career interest in nursing.
Speakers on nursing were sent to schools all over England supplying leaflets, notes, pictures, and posters on nursing and nursing practices. This was coupled by a great deal of press writing that was undertaken at the time. 41
In April 1941, a division of nursing headed by a chief nursing officer was set up at the Ministry of Health.
A salaries committee was established whose chief function consisted in drawing up agreed upon scales of salaries and emoluments for the state registered nurses. The major change resulted in increasing the salary scales of trained and experienced nurses. While these steps were being taken to improve the nurses' pay, progress was also made in the recog- nition of the assistant nurse. The fact that the Civil
Nursing Reserve had recruited assistant nurses for the war implied in itself some official recognition. This and other actions showed that relations between nurses and government
''"^ '"^^ officials were being strengthened. "
Nurse organizations were most active during the war.
The Royal College of Nursing established a committee on
Nursing Reconstruction under the chairmanship of Lord Horder, the King's physician. Many monographs were issued which dealt with standards for nurse training, schools, registration, and the assistant nurse. The recommendation of the committee called for a strengthening of educational programs at all levels of nursing. The committee's report endorsed the assis- tant nurses and gave detailed recommendation on conditions which should qualify for admission, the control of the prac- tice, and the licensing and inspection of institutions train- 1=1^0-^ ing them. 42
Toward the end of 1942 additional measures were needed
for the recruitment of nurses at all levels. A National
Advisory Council for the Recruitment and Distribution of
Nurses and Midv;ives was set up by the Ministry of Health, an
indication that government departments regarded the profes-
sion of nursing as an entity with which co-operative plans
could be made. Nursing officers were then appointed in the
^"^^"^'^ Ministry to " interview and advise the trained nurses .
National Health Scheme
Meanwhile plans were made for a National Health
Service which would certainly increase the demand for nurses.
Under the chairmanship of Robert Wood, a committee was set
up in 1946 to examine questions such as "What is the proper
task of a nurse?" "From what groups of the community should
recruitment be made?" and "How can wastage during training be minimized?" Wastage, according to the committee ' s report, was attributed to hospital discipline, the attitude of senior
staff, and the pressure of work. Results of the job-analysis
undertaken by the committee, showed that nurses devoted
33 percent of their training hours in their first year to
domestic duties, 24 percent in the second year, and 16 percent 1 180 3 in the third year. • " To enable nurses in training to be treated as students, not as maids, the committee suggested the employment of adequate hospital nursing and domestic staff who would relieve the nursing students of unnecessary chores. Another recommendation was that the course of training 43
be dictated by the students' needs, that the financing of
nurse training be independent of the hospital, and that
students be under the direction of a school of nursing rather "^^^"^ than a hospital. ^ '
As a result, a Regional Nurse Training Board was set
up for each hospital region. Planning and coordination of
training facilities, coordination of standards for admission,
and allocation of students to training units were performed by the Boards. In addition, the Boards established advisory
centers to stimulate interest in the nursing profession and
to advise potential nursing students. This system became
the basis for the National Health Service Scheme '"^^"^^
Nationalization of Health Services was established in 1948. The community accepted full responsibility for the care of the sick and hospitals became publicly owned. The
Central Government became the sole provider of care. The country was divided into regions that were then subdivided into areas. Fourteen regional hospitals were delegated to provide hospital services. Boards took control of all the hospitals except the teaching hospitals. The Royal College of Nursing expressed apprehension over all the changes and was among the few institutions that showed concern about the changes in the health professions which might accompany such an arrangement. However, the majority of practicing physi- cians, surgeons, dentists, nurses, and other health personnel accepted appointments under the government. The National 44
Health Service Act recognized two main categories of nurses,
midwives and other health personnel. Private nurses were
excluded and hence continued to offer home services when
hospital conditions prevented the sick from seeking 1^191; 181-2 hospital care. 15:
The Nurses' Act
The Nurses' Act of 1949 brought with it a reorganiza-
tion of regional nurse training centers. For the first time
treasury funds were made available for nursing education.
Some smaller schools were combined to provide a wide range
of experience. However, matrons of hospitals still carried
responsibility for the practical experience of nursing stu-
dents in the Central Government schools. Qualified nurses
employed by the Ministry of Health took responsibility for
inspecting and approving schools, determining standards of
practice, and conducting examinations. Nurses in training
benefited from the Scheme by the fact that their hours and
curriculum were improved and training allowances were granted.
Also, married and part-time nurses were increasingly em- ^^"^ ployed. ^ =
The basic training of the Register and the Roll
remained focused in the hospitals because schools could not manage without trainees. Students, as a result, had little
contact with the family in its natural setting. The policy that much sickness could be treated in the home was not reflected in the basic training of the nurses. Although 45
improvements made in nurses' pay and hours of work contributed
to reducing the opposition of parents and school teachers to nursing as a career, the working environment obviously needed
a change to make it less restrictive and status ridden. Also
the government plan provided little postgraduate education in nursing. As was pointed out, the National Health Scheme was primarily designed for the good of the community and not for 1-210-2 the good of those who would carry out its provisions.
Nursing Education
In 1958, hospitals and public health agencies were
grouped regionally to provide composite training units cov-
ering preventive and curative aspects fundamental to nursing.
The training of a student nurse entailed an introductory period of three months to cover the basic sciences, theory
and practice of nursing, and educational visits to hospi-
tals and agencies; nine weeks of pediatrics with practical
experience in nursery schools and nurseries, children's out- patient departments, and wards; four weeks of obstetrics
in antenatal and postnatal clinics and maternity wards;
four weeks of communicable diseases in clinics and dispen-
saries; ten weeks of medicine with outpatient and ward
experience; thirteen weeks of surgery limited to wards and
operating rooms; four weeks of gynecology; five weeks of public health with a survey of health visiting, school nurs-
ing, and home nursing; and eight weeks of psychiatry, includ-
ing child guidance, outpatients, and wards. The last six 46
4 • 398 months comprised an internship in a chosen field. ' This was planned with the intent on giving the student nurse a
complete status in the profession.
Midwifery schools, like those of nursing, became
separate from the hospital system. The specialized midwife
was required to have the basic course of nursing before
going into midwifery. A one-year training period was required.
It included fifteen weeks on the general principles of mid-
wifery, fifteen weeks on the district, attending patients in
4 • 399 their home, and sixteen weeks on abnormal midwifery.
Health visiting and district nursing were regarded as spe-
cialty areas to follow the basic program. Thus hospital
nursing was seen as a beginning for many other services
instead of as an end. This was intended to help students
adapt hospital methods to home situations and to give them
background knowledge of the services offered to the patient
at home. These services rangetl from teaching preventive
13 • 99- 15 • 183-4 methods to the followup on hospital discharges. >
Present Trends in Nursing Educa t ion
Experiments in nursing education were going on in the
early Sixties. The Glasgow Royal Infirmary offered a two-
year course in basic nursing, followed by a year of intern-
ship before registration was granted. This afforded no
direct link with a university, but students in this plan were
given full university student status. Results showed the
difficulty in compressing theoretical content in two years. 47
At the same time, the Nightingale School of St. Thomas offeree a two-year training course to university graduates. The
Manchester University, during the same period, was offering a university course in nursing which emphasized public health and preventive aspects. This four-year course included public health qualifications which were usually taken on a postregistration basis. This course stressed the fact that nursing can be presented in depth as a university subject, a concept that, by itself, marked the beginning of a new movement in nursing which until then had been hospital
. , 16:56 oriented.^
In the 1970s, nurse training in England for the
General Registry lasts three years and is of an apprentice- ship nature. It is conducted by the nurse- training school staff, which is almost invariably a part of the hospital.
At the end of the three-year period, a final examination consisting of written papers and practical work is adminis- tered. The nurse who passes it becomes eligible for regis-
tration and is given the title ,-:tate Registered Nurse TSRN) .
The Roll, unlike the Registry, requires a two-year training period at the end of which the student becomes a State
''"^ "^^ . ^ Enrolled Nurse (SEN) ' Promotion of a staff nurse to a ward sister requires post basic preparation which is offered in various educational establishments outside hospitals. Postregistration courses in administration or teaching are also available for ward sisters who elect to 48
go into administration or teaching. Such courses are offered at the Royal College of Nursing and the National Council of
Nurses of the United Kingdom and last for one year. 1 5 5 6
The impact of the National Health Service was not as great on nursing as was supposed, for since 1923 nursing had had a national training pattern and a common national examin- ation controlled by the General Nursing Council. However, the National Health Service brought with it conformity with regard to salaries and conditions of service. It also pro- vided great administrative opportunities for nurses at the
Ministerial and regional headquarter levels. The ten-year hospital building plan witnessed the emergence of nursing expertise in all fields. Nurses were on planning committees of all the building projects, v;orking with the medical team.
The General Nursing Council, which is composed of regis- tered nurses, has the responsibility of reporting to the
Ministry of Health on matters in nursing. Thus, the profes- sion in England has the control of its destiny in its own
, , 10:6;11:32 , . • hands. A, deeper inspection of^ the^ present profes- sional scene provides encouragement. The Joint Board of
Clinical Nursing Studies in England and Wales and the Com- mittee for Clinical Nursing Studies in Scotland have planned courses for the development of nursing expertise in a number
''"^ ^"^"'^^ of clinical specialties . " Advanced practitioner courses link the clinical areas with institutions of higher education. In nursing education, also, the situation is far 49
from being static. Innovations and experimentations have
continued in many schools and colleges in Great Britain.
Most students presently gain experience in community as well
as hospital nursing and hence are better able to provide an
integrated concept of nursing care. At the university level,
a number of integrated undergraduate degree/nursing programs
have so far proved highly attractive to prospective nursing
"'"^ students .
Another important link between nursing and higher
education in Great Britain has been the considerable growth
in research activities at the universities and other institu-
tions of advanced education. Research has been mainly con-
cerned with the profession itself— the role, function, status,
.''"^ and education of nurses ' Increasingly emphasis is
also being placed on clinical aspects of investigation and
manpower needs of the profession. Much of this research has
been financed by the government departments whose officers
have also recognized the significance of research in nursing
and hence appointed research specialists in this field. The
usefulness of the research projects in nursing will be in the
provision of information and hard data upon which proper
management of the profession will be based in the future
Nursing Services
At present in England, each patient has a family
doctor, family nurse practitioner, midwife, and pediatric nurse practitioner who work together in the same premises. 50
House calls and follow-up care are done by the visiting nurses who are aided by licensed practical nurses, nursing aides, and home helpers. Carefully trained in handling patients, the nurses in Britain perform clinical procedures with skill the physician sometimes cannot match. The midwives share prenatal and postnatal care with the physician and during labor and delivery they take care of all normal, uninstru- mental procedures. Physicians are always on call to handle unexpected problems. The health visitor, who is comparable to the pediatric nurse practitioner in the United States, runs
• 9 48 • 2 ' well-baby clinics and deals with minor clinical problems. '
Nursing availability and physicians' lowered work load have made it possible to treat at home many patients who might otherwise have been hospitalized. Also, the medical team presently puts more emphasis on the treatment of psychological problems, which are handled mostly by nurses who provide coun- seling and comforting aspects of the care besides the probing and investigating aspects. To make this service more acces- sible, the medical team has expanded to include social workers who take care of the patient's social problems and share them with the rest of the team.^"^^ Such a plan, which is wide- spread in England, provides for more communication and coordi- nation of health services. This in itself constitutes a solu- tion to the National Health Services crisis which for a time burdened the medical as well as the nursing profession. 51
References
1 Abel-Smith, B. A history of the muvsing profession in Great Britain. New York: Springer Publishing, 1960.
2 Briggs, A. Report of the (tommittee on nursing. London: Her Majesty's Stationary Office, 1972.
3 Edwards, M. Nursing in Britain, 1937-1943. American Journal of Nursing, 1944^ 44, 125-135.
4 Fraser, F. The nurse in Great Britain. Canadian Journal of Public Health, 1949, 40, 292-301.
5 Goodall, F. The British citizen and his nurse. Canadian Journal of Public Health, 1947, 38, 151-4.
6 Goodnow, M. Nursing history. Philadelphia: W.B. Saunders, 1955.
7 Henry, F. Trends in England and Wales. International Nursing Review, 1962, 9, 31-3.
8 Jensen, D.M. History and trends of professional nursinq. St. Louis: C.V. Mosby, 1955.
9 Marsh, G.N. Primary medical care. The cooperative solu- tion to the volume problem. Journal of the American Medical Association, 1976, S25, 45-8.
10 Nuttal, P. Nursing in Britain. International Nursinq Review, 1965, 12, 6.
Nursing in England ^^o^^^^' and Wales. Canadian Nurse, 1966, 62, 32.
12 Nutting M.A. and Dock, L.L. A history of nursing (vol. y v 2).y. New York: G.P. Putnam's and Sons, 1910^ . Schuman, 13 M. On the district in England. American Journal oj Nursrng, 1961, 61, 99. Sellew, 14 G. and Ebel, E. A history of nursing (3rd ed.) St. Louis: C.V. Mosby, 1955. Stewart 15 I. and Austin, A. A history of nursinq. New York: G.P. Putnam's and Sons, 1962. Watkin 16 B Nursing in Britain: A year's review. Nursing Outlook, 1964, 12, 56. Wright, 17 M.S. Nursing: Present perspectives and future prospects. Nursing Mirror, 1974, 129, 53-6. 52
Supplementary References
Auld, M. Modern trends in nursing. Nursing Mirror 1976 142(15), 49-51, 54-5.
Brand, K.L. Perils and parallels of women and nursing Nursing Forum, 1975, 14(2), 160-74.
Emblin, R. Degree courses in nursing (part 1). Nursing Times, 1976, 72, 141-3.
Emblin, R. Degree courses in nursing (part 2). Nursing Times, 1976, 72, 145-6.
Fresh perspective on nursing, Nursing Mirror. 1976 , 143(4), 50. y .
Howard, M.H. Activity sampling in nursing. International Journal of Nursing Studies, 1976, 13(1), 47-53.
Nursing in general practice in the re-organized national health service. Journal of the Royal College of General Praatztioner , 1975, 25(157), 593-5. Roper N An image of nursing for the 1970. Nursing Times, 1976, 72(18), 65-6. CHAPTER 2
IRELAND
Irish hospitals and nursing extend back almost to
prehistoric times. The part taken by Irish missionaries in
establishing hospitals in Central Europe is well documented
1 • 183 in history. " Nursing by religious orders in Ireland
dates back to the fifth century when St. Brigid and her nuns
attended the sick. Almost every convent and monastery then
had its hospital and infirmary. Modern aspects of patient
care have been noted in early Irish history. For example,
the importance of peace of mind for patients was emphasized
to the extent that persons and things that did not contribute
to the welfare of the patient were excluded from the sick- 3 ^"^-5 room.
The eighteenth century saw the beginning of modem municipal hospitals. Up-to-date wards, new operating rooms,
and other modem appurtenances were included in most of the hospitals during that period. The institutions were served by untrained attendants. This raised many complaints by physicians and other staff. Early in the nineteenth century, the religious orders of Ireland resumed their hereditary work in nursing and they have carried on with excellence and
53 54
continuous progress in method and scope. ' In 1835,
St. Vincent's Hospital of Charity was established by
Mary Aikenhead, founder of the Irish Sisters of Charity.
The nursing institute of the order dates back to 1883 when
four sisters were sent to the Hopital de la Pitie in Paris
c y . g to undergo a course of instruction in that nursing system.
These sisters were forerunners to many who joined the order
later and devoted their lives to nursing the sick in the wards and instructing others in the practice of nursing.
Mother Catherine McAuley was founder of the Sisters
of Mercy in Dublin in 1831. Sixteen nuns of this order went
to Crimean Hospitals and some outlived Florence Nightingale
there. The Sisters of Mercy recognized the need to educate nurses in modern professional methods. As a result, a school was opened in 1891 in connection with the North Infirmary of
Cork, in which the Sisters had complete charge."'"''" This was
the second secular school opened by Catholic sisters, the
o . 1 q o United States having had the first.
The first impetus toward modern professional nursing
came from the Institution for Training Nurses, founded in
1866 by the Archbishop Trench and his wife. In the 1880s two schools for the training of lay nurses were founded in two old Dublin hospitals. One was headed by Miss Franks at
Madam Stevens Hospital and the other by Margaret Huxley at
Sir Patrick's Dun's Hospital. Opportunities for secular nursing developed slowly because nuns held most of the 55
administrative positions in hospitals, and economic resources ^'^"^ outside churches were limited. ^ '
The Sisters of Charity School of Nursing opened in
1892 in St. Vincent's Hospital in Dublin, where the Sisters
themselves underwent training. The hospital staff was com-
posed of the Sisters of Charity who were trained by the school,
having attended the lectures and passed the examination which
qualified them to register. Nursing students were considered
a part of the staff but were constantly supervised by matrons
day and night. Their work consisted of serving for fixed
periods in medical and surgical wards and attending regular
courses of lecture on anatomy and physiology, hygiene, and medical and surgical nursing. Examinations had to be passed at the end of the four-year training period to become eli- gible to receive the certificate of the Institute. Cooper- ative services were opened in 1906 for institute graduates who
desired . ^ • to remain associated with the hospital ^ Other schools of nursing opened by the Sisters of Charity through- out Ireland included the Training School in the Children's Hospital in Dublin, opened in 1892, and the school in the North Infirmary in Cork with Sister Angela as matron, opened in 1895.12:188-9
The City of Dublin Nursing Institution, founded in 1884 with the aim of helping the City of Dublin Hospital, provided training and employment for Irish nurses. It sup- plied all the nursing in the hospital between 1884 and 1900. 56
Madam Fitzgerald, who had been trained at the City of Dublin
and later in London took up management of the Institute.
This pioneer institution spread out in Ireland and its
branches covered a wide sphere of work. Staff nurses and
probationers were sent to infirmaries in different parts of
Ireland to organize . '"^^"^ nursing arrangements and staf f ing '
Two district nursing centers, one Catholic and the
other Protestant, affiliated with the Queen Victoria Jubilee
Institute in Dublin. Nursing care for the poor and the sick
was carried to the home on a non-sectarian basis. The Queen's
Nurses Magazine, which originated in Ireland and was later
adopted by the Queen's Institute as its official publication,
covered social and political events affecting nurses and their work in the community. One of the leaders in district nurs-
ing at that time was a nurse-midwife. Lady Hermione Blackwood, who was known for her active work in Irish Organization affairs. ^2: 189
Nursing Organization
The Nurses' Association came about as a result of the wide spread of nurse training, which gradually became more systematized and respected. The Association started in 1900 with the finding of a center where nurses could meet to dis- cuss their professional affairs. Later, a committee was formed and elected Margaret Huxley president of the organ- ization. From this Association, the nurses of Dublin Club has sprung and has come to be known for its struggle with .
57
Parliament to obtain registration for nurses. The atmosphere
of brotherhood and equality between medical men and nurses,
and the support of the physicians for nursing problems, espe-
cially in nurse training, is impressive for it is a pleasing
contrast to the story of similar developments in other coun-
. 12:189-90 tries^
Nursing Education
The training of nurses in Ireland today is organized
£1 "7 Q . O O as an apprenticeship. " ~ Most schools of nursing are
attached to hospitals and students function as part of the
nursing team. Hospitals and schools are small, which on one
hand fosters maturity and responsibility but on the other
provides limited experience and opportunities for advanced
training. Many nurses leave Ireland after training, and many ^ potential nurses seek training abroad. ' Ireland was well known for its special emphasis on the mentally handi-
capped and mentally retarded, a dedication which reflects
the influence of St. Vincent de Paul. As a result psychi- atric nurse training has always been separate from that of general nurse training.
Domiciliary Nursing
Following the disbandment of the Queen Victoria
Jubilee Institute, which trained district nurses, Lady
Dudley's Nursing Scheme for the establishment of district nurses in the poorest parts of Ireland was set up in ,
5
9-328 1903. Nurses from this Institute still practice in
Ireland and carry midwifery functions in different parts
of the country.
The first professional organization for nurses,
founded in 1925, was a branch of the National Council of
Great Britain and Ireland, whose journal was The Irish
Trained Nurse and Hospital Review. Upon separation from
the mother branch, the National Council of Nurses in Ire-
land was formed and became a member of the International
Council of Nurses in 1947. A nurse registration law was
then passed to be administered by the Nursing Council of
Ireland. The Nursing Act of 1950 brought with it the annul- ment of the Midv/ives Act of 1918 and subsequently the vir- -^^^"^^ ^ ' ' tual disappearance of the midwife in Ireland. '
The Bord Altranais
Nursing in Ireland is governed hy' An Bord Altranais a statutory body established under the Nurses' Acts of 1950 9-330 and 1961. " This body provides registration for all
trained nurses. It also governs education and registration in basic nursing programs, develops postbasic educational programs, grants scholarships, and undertakes research in nursing. An Bord Altranais conducts a sixth-month course in district public health nursing for students seeking an advanced degree. A two-year nurse/ tutor course is offered by the National University of Ireland for nurses seeking
^ ' ' teaching positions . '
59
The Nursing Bord (An Bord Altvanais ) is independent
and self-supporting. It consists of 23 members, 10 nurse
representatives elected by the profession, and 7 medical
practitioners . The remaining members represent various edu-
12 • 112-3 cational and local authorities. ' Nurse training in
Ireland is laid out by An Bord Altranais , and all training hospitals comply with the conditions, to be recognized.
At present 70 recognized training hospitals exist, 23 in
general nursing, 24 in psychiatric nursing, 5 for mental
handicapped training, and 3 for pediatric nurse train-
. 4:190;13:114 „ ^, . . ^ -, mg. The period of training in alli theseu hos- pitals is three years. Midwifery is considered a specialty
area and can be taken only after general nursing is completed.
Trends in Nursing Education
Male nursing is newly evolving, with students con-
centrating mainly on psychiatric and mental handicap nursing.
Contrary to nursing trends in the world, Ireland trains only
"^^ "^^^ ^^^"^ • ' one grade = of nurse . The curricula are based on two State Examinations, one taken at the end of the first year, the other at the end of the third year. Subjects studied include anatomy, physiology, surgery, medicine, psychology, psychiatry, social medicine, and other health
-^-^ • J-J related subjects. • . Basic education is usually organized by nurse/tutors and clinical teachers. A clinical teacher course is offered by the Bord, whereas the nurse/ tutor course is organized ""-^ by the University of Dublin . 60
Postbasic education is still developing in Ireland. However,
specialist courses are offered by hospitals and cover a
variety of nursing areas. The candidate receives a certi-
ficate at the end of the course which allows for enrollment
• 13:116 m the secondA nurse register.^
Interest increases to develop a university degree in
nursing. ^'^^ The University College of Galway has offered
to establish a degree course in nursing, a suggestion that
was received with mixed feelings by nurses. Since the post-
basic program needs more developing, nurses felt it would be
difficult to accommodate the university graduates into the
hospital system. In any case, plans that are newly formu-
lated will be subject to the approval of the Ministry of
Health. Another opportunity offered to the nursing profes-
sion in the past year is the fellowship brought about by the
Royal College of Surgeons in Ireland. Such a proposal means
an emphasis on the development of research and an opportun-
ity for professional advancement . ''""^ ^~ The whole structure
of nursing in Ireland is going through change and the near
future will witness many new developments in the profession.
National Health Services
A health service legislation similar to that of the
British was passed in Northern Ireland in 1948. The main
difference lies in administration. The Northern Ireland
General Health Services Board, appointed by the Minister of
Health and local government, has the responsibility for .
61
"'"'^^ ^ ' General Medical Services . In the Republic of Ireland,
the Fitzgerald Report in 1967 outlined the recommended
hospital system. Since Irish hospitals are too many, too
small, and too independent of each other, available
resources are thus spread thin. The plan for health
services, as suggested by the Report, entails regional as well as general hospitals with a bed capacity ranging between
330-1000 beds. These main hospitals are set to provide
acute services. County hospitals are changed to become com-
munity health centers, and district hospitals become district
nursing homes. All the hospitals are integrated into one
system with ascending affiliation to the regional teaching ^-^^-^ hospitals.
The emphasis in this plan is obviously on the com- munity health services, as distinct from the hospital ser- vices. However, the services of the health centers are
interrelated and coordinated with hospital services for patient care. This change in the health care delivery
system brought with it considerable change in nursing educa-
tion and service. As a result, nurses are working diligently on restructuring the system by creating Central Colleges of
Nursing instead of the available 69 training institutions.
University degree nursing will be the fruit of such endeavors 62
References
1 Chavasse, J. Nursing in the Emerald Isle. International Nursing Review, 1968^ 15, 183.
2 Dock, L. and Stewart, I. A short history of nursing. New York: G.P. Putnam's Sons, 1938.
3 Dolan, J. History of nursing (12th ed.). Philadelphia: W.B. Saunders, 1968.
4 Elms, R.R. Irish nursing at the crossroads. Inter- national Journal of Nursing Studies, 197U, 21, 163-72. Northern 5 Grey, M. The nursing and midwifery services of Ireland. International Journal of Nursing Studies, 196h, 1, 145. Ireland. 6 Leydon, I. Development of nursing education in challenges of the future. . . . Training to meet the International Journal of Nursing Studies, 1912>, 10, 95-101.
(vol. 2). 7 Nutting, M.A. and Dock, L.L. A history of nursing New York: G.P. Putnam's Sons, 1910.
8 O'Carrol, M.F. Restructuring the health care system—An Irish solution. World Hospital, 1911, 7, 45-9.
9 Reidy, M. The history of nursing in Ireland. Inter- national Nursing Rei-^iew , 1971, 18, 326-33.
10 Scanlar, M. Nursing education in Ireland. International Nursing Review, 1969, 16, 153.
11 Sellew, G. and Ebel, E. A history of nursing (3rd ed.). St. Louis: C.V. Mosby, 1955.
12 Stewart, I. and Austin, A. A history of nursing. New York: G.P. Putnam's and Sons, 1962.
13 Temey, B. Nursing in Ireland. International Journal of Nursing Studies, 1974, 11, 111-7. CHAPTER 3
GERMANY
Nursing in Germany, as in other European countries, was done chiefly under the auspices of religious groups:
Protestant and Catholic. In the nineteenth century, hos- pitals were mainly under control of the government in spite
of the fact that they were staffed by religious orders
In 1836 Theodore Fleidner, pastor of a Protestant church at
Kaiserwerth on- the-Rhine , introduced the German model school of nursing which prepared deaconesses for teaching or nurs- ing. This movement was carried later by deaconesses who
transplanted it in different parts of the world. At the same time Catholic nursing orders were active in most parts ^=^03-4 of Germany.
In 1863, National Red Cross societies were formed and about forty Red Cross Hospitals were opened. These societies were active in training nurses in both short and long courses. The Motherhouse system, patterned after monasteries, was spread by the Kaiserwerth Deaconesses and the Red Cross Hospitals. Nurses under this system remained associated with the schools, and governed by them, even after graduation. As a result, a great demand was put on nurses
63 .
64
by hospitals, and the nurses had little autonomy in such 12:303 matters
With the outbreak of the Franco-Russian War in 1870, military hospitals overflowed with the injured. As a result, the Empress Frederick consulted Florence Nightingale in
England who sent Florence Lees, one of her expert nurses to 12-303 give advice and help. ' This led to the spread of nurs- ing education on a broad community basis. The Victoria
House, named after the Empress, was established in Berlin and incorporated many elements of the Motherhouse system.
In this system nurses in training could apply for membership in a secular sisterhood. The German Red Cross followed much the same system later in reorganizing its training on a national basis. The Motherhouse of the Red Cross Sisters gave more freedom to its members in allowing them to join cultural and social activities and in handling their own economic affairs, contrary to the system that was followed by the religious sisters who assumed control of the nurses
12 ' 304 that belonged to their sisterhood.
The German Nurses' Association
As a result of dissatisfaction with policies of the
Motherhouse, which was having difficulty in supporting its members, a group of nurses broke away from the mother organ- ization and became known as Free Sisters or Wild Sisters
5 * 3 A 2 3 of Germany. ' These sisters banded together and chose
Sister Agnes Karll as leader. Through the effort of this 65
group of nurses the German Nurses' Association was organized in 1903 with Sister Agnes Karll as first president. In 1906, the Association published its first journal, Untevm Lazarus
Kveutz, a militant organ of the organization. When the
International Council of Nurses met in Berlin in 1904, the
English, Irish, and American nurses assembled were graciously
9*26 2 welcomed by Sister Agnes Karll. ' This was the begin- ning of a friendship among nurses in the world which with- stood the strain and stress of the two VJorld Wars.
Agnes Karll prepared the way for nursing to be accepted as a free and undenominational profession. She proved that nursing could be founded on ethical motives even without allegiance to the church. From the start she empha- sized the importance of a three-year training program, a goal which was achieved 50 years later. Between 1909 and 1912 she was president of the International Council of Nurses and hence contributed much to the development of nursing as
r . 4:43 a profession.
Nursing Registration
The German nurses, who had such difficulty in organ- ization, carried registration through in a surprisingly
7 9 fi 7 short time and with little opposition. Legal regula- tion has always been in harmony with German philosophy and policies. This step resulted in disorganization and dis- order among nurses, and nursing standards became notorious.
Many nurses who took short courses by physicians and who 66
had been practicing for some time, claimed a right to be
included in the registry. This continued until the Act was
set by the Federal Council in 1905 abolishing short courses
12 : -, -, • . ^ 305 . and calling for.r the^ training of nurses. The, German^ Regis-„
tration Act required one year of study and hospital training
to be followed by a government examination at the end of the
training period. In spite of all this, in Germany as a whole, persons who had hospital experience through practice,
and who passed the State examination, whether they had
• 9 ' 28 entered a school or not, were allowed to be registered.
The German Nurses Association under the leadership of
Sister Agnes Karll did much to raise nursing standards and
published many studies on the serious health conditions that
afflicted nurses at that time. As a result of the Associa-
tion's strenuous efforts, the government intervened to improve working hours, salaries, and working conditions of nurses
"''^ ' '^^'^'^ which were described as being very poor.
Social Insurance in Germany
The development of nursing in Germany has to be
considered, in part, in relation to the policies of Bismark
'"^ who forestalled the progress of socialism. • Social
security for the working classes took major importance in his reign, resulting in the institution of the compulsory Social
Insurance Act in 1883. This obliged wage earners and low- salaried employees in trades and occupations that are prone
to high accident rates to seek membership in health insurance 67
organizations. In 1923, various professional groups, includ-
ing teachers and practicing nurses, were brought under the
system. ' Evidently Bismark's program was one of the
earliest and most comprehensive of social insurance schemes
to influence the medical and nursing fields. The health
insurance plan in effect at present dates back to 1883.
The National Federation of Nurses
When Hitler came into power in 1933 all nurses came
to be included in the National Federation of Nurses and
Attendants. " Since that time important changes have
taken place in nursing organization, education, and practice.
The Federation comprised the Catholic nursing orders, the
Protestant nursing orders or the Deaconesses, the Red Cross nursing sisterhoods, the Professional Association of Nurses (The Berufsorganisation der Krankenpf legerinnen) , The National
Association of Pediatric Nurses, and the National Socialist ^'^^^ Sisterhood of Nurses. The National Council of Nursing founded in 1936, and composed of two representatives from each of the national nursing organizations, exercised no power in determining the work of any of the above-mentioned organizations. However, through its journal, The German Nurse (Die Deutsche Schwester) , it demonstrated considerable influence on """^ " -^^^"^ nursing practices . 68
Nursing Education
The Nursing Act of 1938 put the education and ^'^^^ practice of nursing on an entirely new basis. A uni-
form nursing education was established for the entire
Reich and the practice of nursing was limited to licensed nurses. Applicants to schools of nursing, under the law, should be at least 18 years of age, must be graduates of a primary school, pass a physical examination, and prove
that they had completed at least one year of work in a household of children or in a school. The nursing course extended over one and a half years after which the graduate nurse was obliged to continue to work under supervision for an additional year,^"'^^^ Nursing practice then was the cornerstone for nursing education. Theory supplemented practice and included lectures on ethics, anatomy and phys- iology, pathology, nutrition, public health nursing, and social ^ ' '^^'^"^ insurance laws . Physical education was com- pulsory for all students.
All public hospitals under the new law were to organize and maintain schools of nursing with subsidies provided by the government when needed. The physician was the person responsible for directing activities of the school and for administering the theoretical part of the program. Graduate nurses took care of the clinical part of "^^ " teaching student nurses .
After the Nazis' defeat, different nursing groups withdrew into their own closed circles and little attempt 69
was made to reunite them. To have accomplished this would
have been difficult in any case because Germany was then
divided into four zones under British, French, American, 12 • 309 and Russian control. ' In American-occupied West Germany
some followers of Sister Agnes Karll revived the German
Nurses Association and in 1948 the German Nurses Federation
was formed which included the Agnes Karll group and the Red
11 • 993 Cross society. ' This newly founded association was
admitted to .'"^ "^"^^ the International Council of Nurses in 1949 '
Collegiate Nurse Training
In the early 1950s, a modern collegiate school of nursing was opened at the University of Heidelberg. It pro-
vided a broad and sound basic nursing program on a university
level as well as postgraduate programs in public health nurs-
• 12 ' 310 mg and nursing education. ^ Training schools for the Red Cross nurses were conducted by Motherhouses . In payment
for the professional training they receive. Red Cross nurses were obliged to stay with the organization for four years
following graduation. ^'^ Public health nursing at the basic level was virtually unheard of in Germany. Health instruction and health care of patients were left in the hands of untrained assistant nurses. The Red Cross schools took the lead, then, in training assistant nurses or nurses' aides who provided a variety of services in the civilian and "'"^ ^'-^'^ military domains . ' •
70
The training of nurses in West Germany presently
consists of a three-year course with a minimum of 1200 hours
of instruction. A final examination is usually conducted
by the teaching staff and a State representative."^'''''
A training school is required by law to be associated with
a hospital which should provide adequate theoretical and
practical training in internal medicine, surgery, gynecol-
ogy, and psychiatry. Schools for children's nurses are
associated in the same way with children's hospitals . ^
Training schools are headed by a matron, a senior sister, and a doctor. Advanced training for nurses is not governed by law. Training for clinical specialties is organized by the hospitals in courses of range from two months to one
year. Training for nurse aides lasts one year with 250
hours of instruction. All schools of nursing are expected to be affiliated with hospitals and should be recognized by the 3 • 7 7 State. • More emphasis is being placed on the recruit- ment of male students into the nursing profession, a trend developing in many parts of the world. This is attributed
to the short life-work span of a female nurse, averaging between five to six years, whereas that of the male nurse is 40-45 years.
Present Concerns in German Nursing Education
Many concerns have been raised by professionals regarding the lack of continuity between theory and practice 71
in the nursing field. The main argument is that schools are emphasizing theory at the expense of practice. They feel nursing is a practical field whose complexity can be acknowledged only in the light of practice. They feel students can learn better in the actual situation where expectations can be fulfilled by the reality of the situa- tion. Psychomotor skills, daily routines, communication and interaction with patients are better learned at the bedside than from books, is the present trend. To remedy the situation they recommend that nurse- instructors should be practitioners as well as administrators and principals of schools of nursing. In their view, all incoming students should have a scientific background so that the time they spen( in learning nursing skills should not be interrupted. They also recommend that all nurses be subjected to continuing education programs to stay up to date with scientific 7^250-3 methods. 72
References
1 Cowen, E. The six: Social services (part 4). Nursing Mirror, 1972, 134, 26-8.
2 Dock, L. and Stewart, I. A short history of nursing. New York: G.P. Putnam's Sons, 1938.
3 Eichhorn, S. Trends in the professional education of doctors, nurses, and other paramedical staff in the German Federal Republic. World Hospital, 1969, 5, 77.
4 Fricke, A. Agnes Karll. International Nursing Review, 1967, 14, 43-4.
5 Goodnow, M. Nursing history (9th ed.). Philadelphia: W.B. Saunders, 1955.
6 Jameison, E., Sewall, M. and Suhrie, E. Trends in nursing history (6th ed.). Philadelphia: W.B. Saunders Co., 1966
7 Katscher, L. Current status of nursing education. Deutsche Krankenp fie g zeits ahri ft , 1976, 29(5), 250-3. (German)
3 Kroeger, G. Nursing in Germany. American Journal of Nursing, 1939, 39, 483-5.
9 Nutting, M.A. and Dock, L.L. A history of nursing (part 3). New York: G.P. Putnam's Sons, 1910.
10 Sellew, G. and Ebel, E. A history of nursing (3rd ed.). St. Louis: C.V. Mosby, 1955.
11 Setzler, L. Nursing and nursing education in Germany. American Journal of Nursing, 1945, 45, 993-5.
12 Stewart, I. and Austin, A. A history of nursing. New York: G.P. Putnam's Sons, 1962.
13 Weigand, E. Nurses of the German Red Cross. American Journal of Nursing, 1949, 49, 218-9. .
CHAPTER 4
HOLLAND
Early Training of Nurses
In the Middle Ages, nursing of the sick in Holland was chiefly the task of religious corporations, especially
those of Roman Catholic orders. For more than four centur-
ies the Brothers of St. Johannes de Deo have devoted them- 16 55 selves to the care of their suffering fellow- members
Many nursing sisterhoods are also of ancient date. Prot-
estant deaconesses took up the work of charity in 1830 and
established their first home in 1843 in Utrecht. This move-
ment was followed by the establishment of many other insti-
tutions which spread throughout the country. Some of these
houses were later affiliated with the Kaiserwerth Association
'"^ in Germany . Besides doing patient care in the institu-
tions, the sisters devoted the rest of their time to district nursing.
In 1874, the White Cross Association of North Holland was formed through the efforts of many philanthropic groups.
This brought with it the first attempt in Holland to train women of good standing and education outside the Motherhouse
system of the deaconesses. A committee on training nurses,
set up by the Association, was composed entirely of men.
73 .
74
The first three nurses were trained in Amsterdam in 1879,
and received certificates upon the completion of the train- 4 mg course. The high standards of this association brought
about many hospital reforms which took effect in the Wilhel-
mina, a prominent hospital in Amsterdam, as early as 1890.
These reforms were attributed to the work of a Miss Reynvaan
who, like Florence Nightingale in England, went out of a cul-
tured home to improve the the deplorable methods of nursing care
The training of probationers and nurses at the
Wilhelmina hospital consisted of a three-year course cover-
ing basic anatomy and physiology, medical-surgical, and fever nursing, first aid, foods, hygiene, and nursing ethics.
Women of every class and denomination were accepted as proba-
6 * X 3 6 tioners, ' Students depended on the good will of nurses
for instruction in the clinical areas or upon their own
capacity to acquire knowledge. As a result the probationer was never considered as a student but from the beginning of
"'^^ her ' training was a part of the staf f .
Nursing was not focused solely on the hospital in
Holland, for district nursing was carried all along by reli- gious as well as secular societies. Many private institu- tions for district nursing were founded on the broad prin- ciple of human solidarity, such as the Rotterdam, Amsterdam, and The Hague Societies for District Nursing which sent out
"'•^ •'^^ visiting nurses to the = different dis tricts . The
Association of the White Cross, and the Haarlem Nursing ^
75
Associations also sent out nurses who carried on private
nursing duties. Nurses in the former group received fixed
salaries whereas those of the latter group had their own
r: 15:56 fullf fees.
Early Nursing Organizations
The Dutch Association for Sick-nursing (de Nederland-
sche Bond voor Ziekenverpleging) , founded in 1892, proposed
to raise the level of nursing by bringing about order and
uniformity in training and examinations. The Bond, as the
Association was called, had little influence in bringing about major reforms in the nursing profession. In 1899, the Inter-
national Council of Nurses invited Miss Reynavaan and another
19 • 'il Q nurse to attend its meeting in England. In 1900,
The Nosokomos (the Greek word for nurse) was formed with the
cooperation of leading feminists and supporting physicians.
Mrs. Alertina, the first president of the Nosokomos, had
realized, during her training at the Children's Hospital in
Rotterdam, how incomplete the nursing education system was,
coupled with the enormous need for more solidarity among nurses. Dr. Alertina, like Dr. Fenwick in England, cham- pioned the nurses' cause and, together with his wife, worked
on uniting nurses in one association, and conducted campaigns
"'"^ ^ ' to obtain better conditions for nurses .
J. C. van Lanschot Hubrecht , attracted by the
Alertinas, devoted her time to the advancement of the educa- tional and ethical standards of nursing. Nosokomis^ a militant publication of Nosokomos, was used by J . C. van Hubrecht to 76
attack every stronghold of power related to the work of nursing. Efforts were being made then to achieve State registration, a movement strongly opposed by the Boards of
Deaconesses and other groups of religious nursing orders.
After many years of continuous struggle, the registration law was finally passed in 1921. Though its members were not
satisfied with its details, they accepted it as a fair
, . . 17:2A3;18:246 beginning.
The Nosokomos gave keen attention to the conditions of nursing work. It ur^;;ed the eight-hour schedule and
declared that students should be treated as such. It insti-
tuted its own examination and insisted that nursing schools should come under the Ministry of Education. In addition,
Nosokomos translated and published books and conducted courses for graduate nurses in obstetrics, pediatrics, public
^•'^ health, psychiatry, teaching, and adminis tration .
In 1928, the Nosokomos was replaced by a large and more inclusive organization of registered nurses called the
National Association of Nurses of the Netherlands, which was accepted by the International Council of Nurses the same year.''"^'^^ Only nurses with full general training were active voting members; all others were associate members.
Training in schools then covered three years and three months.
Preliminary courses v/erc offered in the three-month period and the actual training of the general sick-nurse took three years. This excluded obstetrics, mental diseases, and public 77
health nursing, which were offered as postgraduate courses.
An admission examination was administered to all prospective
students and admission into the program was based on responses
to the examination. The proportion of theory to practice in
"'""'"^^ hours was 1 : 11 . 5 Thus, emphasis in nursing education was mainly on hospital training.
Training Programs
Two types of nursing schools existed in Holland in
the 1940s: those granting their graduates the "diploma A" in general nursing which included medical, surgical, pediatric, tuberculosis, and communicable disease nursing, and those granting "diploma B" in mental nursing. A nurse with an
"A diploma" could take the examination for a "B diploma" after a year and a half of training at a mental hospital. A "B diploma" nurse could become an "A diploma" nurse after a min- imum of two ^ ' '^^^ years of training at a general hospital .
After completion of either the A or B diploma and after pass- ing the State examination, the nurse received a State certi- ficate which allowed her name to be entered in the Register.
She was then called a State Registered Nurse or
Public Health Nursing
Much of the public health work in Holland was done by private agencies with State subsidies and State supervision. The most important public health associations at present are 78
the Green Cross, the \^^ite-Yellow Cross, and the Orange Cross.
Trained nurses in these agencies give bedside care to patients in their homes and teach families the principles of disease 1 26 5 762 prevention. ' ' ' Public health training requires a basic nursing diploma and an additional one year of postgraduate work in maternity and district nursing.
Professional Nursing
Up to this point all training was done in the hospital.
However, when training institutes were completely separated from the hospitals, professional orientation to nursing was developed with bedside training supplementing rather than dominating theoretical instruction.''"^ At present general training lasts three and a half years, with more emphasis placed on theory in psychology, sociology, physics, chemistry, bacteriology, pathology, and vocational training with related coursework than training in the past. clinical experience covers a variety of specialties, with two- to six-months practice in each area. Hospital examination is carried at 7:136 the endA off every year.
In order to secure better hours, salaries, and working conditions, nurses joined other unions. A consequence of this was the formation of a federation of professional and nonprofessional nurses organization headed by Miss Minelda, then president of the National Nurses' Association . ''"^ '
The appointment of a leading nurse to the Ministry of Public 79
Health constituted the first step in bringing governmental g reform into nursing practice and education.
Changes in nursing education were introduced late in the 1960s. In 1969, a committee of health personnel met to discuss the status of the nursing profession. The con- sensus among members present, including government officials, was that
(1) nursing education should be governed by the same law that regulates secondary education,
(2) students should be granted full status, as students and not as hospital employees,
(3) training should prepare professional nurses and should have continuity and sequence,
(4) basic nursing education should prepare graduates to function in all fields of health care, and
(5) the program should focus on development of the students' personality . 2 : 409
These recommendations were adopted by the government early in the 1970s and are presently instituted in many cities in Holland. These programs are under the Ministry of
Public Health, which exercises control over the standards of the schools. Students admitted to the intermediate nursing programs (M. B . 0 (see Fij^,ure . ) 1) , undergo a three-year training period comparable to the diploma program in the United States.
This prepares them to carry on nursing functions in all nurs- 2=^^0-11 ing fields.
Higher professional education in nursing (H.B.O.) is another development in nursing education in Holland. These programs, regulated by the Ministry of Education, offer 80
W.O. wetenschappelijk onderwijs university education
H.B.O. hoger beroepsonderwijs vocational education, higher level M.B. 0. middelbaar beroepsonderwijs vocational education, intermediate level L.B.O. lager beroepsonderwijs vocational education, lower level V.W.O. voorbereidend wetenschappelijk onderwijs pre-university education H.A. V.O. hoger algemeen vooitgezet general secondary education, onderwijs higher level M.A.V.O. middelbaar algemeen general secondary education, voortgezet onderwijs intermediate level
1
H.B.O. i 3-5 years M.B.O. 3-4 years
1 V.W.O. 1 6 years H.A. V.O. ^ 5 years M.A.V.O. 4(3) years
1 Primary education 6 years
Figure 1. Educational System in the Netherlands.
From: Ministry of Education and Science et al. Vademecum: A concise guide to study- ^.n^^tn the Netherlands. The Netherlands, 81
a four-year course in basic nursing education. These pro-
grams, though outside the University, are comparable to
undergraduate nursing programs in the United States. Many
nursing educators are presently working to develop a uni-
versity degree in nursing to prepare nurses for teaching
positions ^ " in the different programs .
Future Trends
In the near future, most nursing labor in Holland
will be done by graduates of the intermediate nursing pro-
grams, whereas the higher education graduates will concen-
trate mainly on staff functions. University graduates will be utilized for teaching positions at the two levels as well
as in higher positions in the health care arena. Since
secondary and higher education programs in nursing are
presently under two different departments, the Ministry of
Public Health and the Ministry of Education respectively,
coordination is hard to achieve. The transfer of the secon- dary nursing program to the auspices of the Ministry of Edu- cation is one of the goals nurses are trying to achieve in Holland. 2 =^15- 16
Health Care System
Health insurance covers most of the population in the Netherlands at present. Employed persons with limited income are compulsorily insured, the insurance covering the whole family. All persons 65 and older are insured the same .
82
way. Self-employed people with limited incomes can insure
with the same companies, known as the sick funds, v^hich
cover some 70 percent of the population. The rest of the
population takes up other insurance through commercial 20:147 companies
The number of nurses has increased substantially
during the past 25 years in spite of the fact that entry
requirements have become more demanding. In 1970 Holland
had approximately 68,000 nurses; about 7000 of them were
men, and 750 were midwives who did approximately one- third
'"^^ of the deliveries . Graduates of the intermediate
program of nursing in Holland function as family nurse
practitioners and pediatric nurse practitioners. Many of
these nurses work in institutions for the aged, agencies
"7 9 • / 1 found in abundance in the country.
In the Netherlands the central authority responsible
for health services is the Ministry of Social Affairs and
Public Health. Voluntary organizations with government
subsidies carry on most of the preventive work in the health
care delivery system. Curative care is delivered mainly by
private agencies. General practitioners are private entre-
preneurs, as are " most of the specialis ts . "'"'^ Only a minority of hospitals are presently run by the State; the majority are private, non-profit corporations. Regionaliza-
tion for the purpose of promoting coordination is emerging
in Holland. This constitutes regional health care delivery 7
83
systems and integration of different institutions of health
care. Regionally, health care education will be the respon-
sibility of government local officials, nursing teachers,
' and nursing administrators. 2 " A 1
General Framework of Health Activities
In the Netherlands, private agencies play a peculiar
position in the delivery of preventive medicine and medical
care, contrary to most countries in the world. 9 The organ-
ization of these private agencies is on a denominational
basis. The Roman Catholic organizations cover one third of
the population, the Protestants cover a little less, while
the rest are nondenominational . The Cross organizations are
the largest in public health and preventive medicine and are
nationwide organizations represented by provincial officers
and local branches in the municipalities. Family care as well as medical care in any field in the health profession
should be provided by medical and health personnel of the
same denomination as the family. This means that the Green
Cross Organizations serve the general group or the nondenom-
inational public, the White-Yellow Cross serves the Roman
Catholics, and the Orange-Green Cross serves the Protestants.
This principle in the Netherlands not only holds in medical and preventive care but also applies to hospitals founded on a denominational basis and to all fields of social and cul- ''"^ tural life. 84
Apart from the Cross organizations, other agencies are also involved in specific fields of health care. Child guidance clinics, marital and family guidance centers, dis- pensaries for alcoholics, and social and psychiatric services have infringed on the role of the nurse in the country. Nurses see to it that mental health principles are taken care of in many different kinds of health activ- ities, as child protection, care of unmarried mothers, care of problem families, rehabilitation of the handicapped,
child health and welfare, and others. National organiza-
tions have been formed to stimulate more interest in this work. They include the Federation of Child Guidance Clinics and the Federation of Agencies for Alcohol Control, that
deal with preventive mental health practice. The various national organizations which, until recently, have been func-
tioning on a denominational basis are now' preparing one joint
1 3 • 8 federation to undertake all tasks in mental health care.
The provincial government has the responsibility of supervising to a certain extent all the municipal agencies.
Recently provincial councils for public health have been formed and act as advisory bodies representing the local authorities. This step is intended to bring the provincial government into an active role in health matters. At the government level responsibility for public health rests with the Minister of Social Affairs and Public Health. The formu- lation of policy, legislation, and budgetary matters is handled by the General Directorate of Public Health.^ 85
References
1 Cowen, E. The six: Social services. Nursing Mirror, 1912, 134, 24-6.
2 De Haan, M.C. The Student of the Intermediate Profes- sional Nursing Education in training and practice. (2) Nursing Education in future perspective.
Tijdsahrift Voor Ziekenverpleging , 1976, 29(9), 408-17 (Dutch)
3 Dock, L. The progress of registration in Holland and Australia. American Journal of Nursing, 1905, 5, 318-9.
4 Dock, L. and Stewart, I. A short history of nursing. New York: G.P. Putnam's Sons, 1938.
Hooykaas S. 5 , Nursing in the Netherlands. American Journal of Nursing, 19U6, 46, 760-2.
6 Kingdom of the Netherlands. Facts and figures. The Netherlands, 1970-71.
7 Kruysee, M. The training of nurses in the Wilhelmina Hospital, Amsterdam, Holland. American Journal of Nursing, 1901, 2, 136-7.
8 McCarrick, H. Holland: Sense and sensibility. Nursinq Times, 1913, 69, 1424.
9 Meijer-Neels E. , Part-time nursing in Holland. Nursinq Mirror, 1958, 106, 1149-50.
10 Melk, H.A. A glimpse into nursing and nursing education in Holland. International Nursing Review, 1932, 7, 185-8.
11 Melk, H.H. A friendly comparison. American Journal of Nursing, 1930, SO, 1103-9.
12 Ministry of Education and Science et al. Vademecwn: A concise guide to studying in the Netherlands. The Netherlands, 1975.
13 Ministry of Public Health and Environmental Hygiene. Mental health in the Netherlands . The Netherlands, 1972.
14 Mok, A.L. Continuity and discontinuity in the nursing 296^309^°"' Nursing Review, 1969, 16,
(pictorial). American ?Q?Q°"oi^"^n°'''^ Journal of Nursing, 86
16 Nutting, M.A. and Dock, L.L. A history of nursing (vol. 4). New York: G.P. Putnam's Sons, 1910.
17 Sellew, G. and Ebel, E. A history of nursing (3rd ed.). St. Louis: C.V. Mosby, 1955.
18 Seymer, L. A general history of nursing. London: Faber and Faber Limited, 1935.
19 Stewart, I. and Austin, A. A history of nursing. New York: G.P. Putnam's Sons, 1962.
20 Stolte, E. Health services in the Netherlands. World Hospital, 1970, 6, 147. CHAPTER 5
FRANCE
Throughout the early history of France, religious
orders of the Catholic church did nursing among the poor
and the sick. The organization of the Sisters of Charity by St. Vincent de Paul and St. Louise de Marillac in 1633 was an event of great significance in the history of nurs-
ing reform, growing later to become an international move- -^^^ T^e^T^t.^^ After the Franco-Prussian War in 1870, serious
attempts were made in Paris by the "Assistance Publique" under Dr. Bourneville to improve the training and practice of nursing. As a result courses were started at the
Salpetriere and the Bicetre in 1878 which ' emphasized the importance of theoretical instruction in the education of nurses. Although Dr. Bourneville did not have a woman director, such as the English matron, he was a firm believer
that . • nursing procedures should be taught by nurses ^^^'^^ Nurse certificates were awarded at the end of the course to those who qualified by attendance and examination. Many improvements in working conditions, hours, and wages came about as a result of the continuous fight of Dr. Bourneville
-^^'^ for ' reform in nursing .
87 88
The establishment of the Red Cross hospitals in many
European countries brought with it tremendous improvement
in nursing practice. Nurses were trained for work in the home and for ' service in wartime . In 1900, a small
school with its paying hospital and out-patient department
was established by Madam Alphen Salvador in the Rue Amyot
in Paris. This school, under the Assoaiation pour le
Development de I' Assistance aux Malades, trained young women
for private duty nursing in a two-year course. A diploma
was issued to students at the end of three years of hospi- 22-50 tal work. ' In 1905, a similar Parisian school called
the Maison Ecole d' Inf irmieres Privees . was started by
Mademoiselle L. Chaptal. Students lived in the school
where they had their lectures. Practical experience covered
work done in different hospitals in the area with direct
supervision from ' the school . The Certificat de Fin
d'Etudes was granted to the students who successfully
completed the program. Both schools had a competent teach-
ing system for the times, but the practical part of the
instruction was somewhat deficient due to the lack of
^ • -^^ • ^'^^ systematic hospital training . '
The Nightingale System
The Nightingale system was introduced to France in
1901 by a woman physician. Dr. Anna Hamilton. Like Florence
Nightingale, she was born near Florence, Italy. Her father was English, her mother French. As a medical student she 89
observed crudeness and inefficiency in the care of hospital
patients. Her doctoral dissertation on the care of the sick
in hospitals, Considerations sur des Infirmieres Hopitaux,
exposed the poor nursing methods and criticized the French 9-401- 21-471 ' nursing system. ' Dr. Hamilton did her best to
educate and enlighten public authorities on the importance
of hospital training for nurses, an effort that encountered
resistance by top governmental officials. Being a firm
believer of the Nightingale system which she had studied
through visits to England, she took charge of the Maison de
Sante Protestante at Bordeaux and appointed an English nurse,
Miss Catherine Els ton, to head the newly organized training
school, ^' ''^^ later named after Florence Nightingale .
Dr. Hamilton's plan had the full support of Dr. Lande, mayor
of the town, who was planning on establishing a similar
school in his municipal hospital. His school became the
pioneer ' institution in nursing education in France .
Other hospitals soon followed the same program for their nurse training which was adopted by Paris in 1907 under the
direction of the Director-General of the Paris Department of ^- -"-^^"^ Public Charities .
Such a movement came about as a result of the severe
conflict between Church and State, resulting in termination of the services of some religious orders that opposed the nursing reform. This was known as the "Laicisation of "'"^^ 9:316;24:328 • French Hospitals . ' . ,
90
Dr. Hamilton's approach to the training of nurses can be summed up in the following:
(1) selection of women of education,
(2) education combining lectures and ward experience that provided constant supervision of proba- tioners,
(3) simple theoretical instruction accompanying practice
(4) a diploma granted upon the demonstration of theoretical as well as practical knowledge of nursing procedures.
(5) designation of the trained nurse as the person responsible on the ynit for carrying out staff nursing function. 10:202-3
Nursing Organization
The social structure of France at the time was not favorable to a high and rapid development of nursing.
Young French women were protected and sheltered by their parents. Thus, on the whole they were not well educated and tended to marry early. Recruiting educated girls for nursing was difficult, hence, candidates were obtained from
i the lower strata of society. World War I broke down this convention and, as a result, more parents were willing to allow their daughters to enter the nursing profession. This boosted the status of the profession con- siderably 22:245
The war experience in general contributed to the promotion of modern nursing in the world. Nurses of Great
Britain, America, and France worked together for a common 91
cause and exchanged ideas, which stimulated many interests
'^^'^ ' for nursing improvement . Mademoiselle Chaptal and
Mademoiselle de Joannis , both directors of private nursing schools, became leaders of the revitalized movement. Their influence led the French government sometime after the war to institute a state diploma and to establish a general nursing council which designated the requirements schools of 15-203 nursing were required to meet. " With the support of influential religious and civil groups, state registration became effective in 1922, giving legal recognition to nurses
who had received regular training. ' In 1923, the
National Association of Graduate Nurses of France was formed with Mademoiselle Chaptal as first president, and The French.
Nurse^ L' Infirmiere Franoaise, as its official journal. In
1924, all applicants were obliged by law to pass a state
"'"'^ "^^^ ' ' examination before registration was granted . '
The Association of the French Nurses brought the secular and religious orders together by including nuns, protestant deaconesses, graduates of the Nightingale, Red
Cross, and other schools that offered nursing courses of 1Q / r\'\ OQj-jJQQT two or more years duration. " . Sisters from many orders went back to training schools to take the State diploma. Four orders opened nursing schools for secular nurses and religious sisters; two were St. Vincent de Paul
^ and the Augus tinians .''"^ 8
This group of professionals was weak compared with
the large trade unions that were then backed by political
power. Professional nurses found it difficult to compete
with the unions especially as to salaries and positions,
for nonprofessional or lay nurses outnumbered trained nurses. " The City hospitals' nonprofessional nurses,
both men and women, were grouped in a trade union affiliate
with the Confederation General du Travail. One of their
aims was the suppression of all nursing schools and the
establishment of one school where anyone can join as a
student nurse. ' This went on until the French govern- ment in 1937 passed an Act which forbade anyone to practice
as a nurse, in a hospital or public health agency, without ^ ''^ having the State diploma.-""^-
Nursing Education
As regard to education, the decree established a two-year curriculum for hospital training, three years with public health training. Schools of nursing were allowed to prepare students if they fulfilled the requirement of the adopted curriculum that stipulated practical and theo- retical training, length of the training period, age of the pupils (20-35 years), previous education of students with the high school diploma as the minimum level for admission. Students were to pass theoretical and practical examination before a jury of eight members chosen by the Ministry of Health. 5 80 ' At the same time the Council on Nursing .
93
Education was formed, Conseil de Pe rfe a tionnement des
Eaoles d'Infirmieres, which studied changes and improvements to be instituted in the new curriculum. This led to changes in the curricula of many nursing schools that were applying ^'^^^ to become members of the Board. Members of the Conseil
de Perfectionnement were chosen from among doctors , direc- tors of schools, public health nurses, and members of the department in the Ministry of Health responsible for health questions. In July 1925, the Central Nursing Bureau was opened under the direction of Mademoiselle de Joannis to keep the State Register, inspect schools, and conduct examin- 4:297-8 ations
In World War II, France was invaded by the Germans first, then by the allies, resulting in the destruction of many nursing schools. When the Nazis left, many schools reopened immediately with the help of the. Rockefeller Foun- dation and '"^ "^'^"^ the ' Red Cross Welfare centers . In the midst of the war in 1943, France passed a law protecting
. ''•^ " -^"^-"^ -^-^-^ the title of • the registered nurse ' In 1946, another law was passed which placed the nursing profession under the Ministry of Health, giving the nurses more prefer-
''^^ ence in " the filling of State posi tions .
Training of registered nurses today takes place in some 250 public or private schools, some of which are linked to hospitals. One is under the Ministry of Education; the rest are under the Ministry of Social Af fairs -"-^^ Courses 94
raJi for three years during which nursing students receive
22 hours per week of hospital training. Theoretical
instruction takes place at the school itself, usually given
by doctors and nurses. Considerable emphasis in the nurs-
ing program is placed on the medical and surgical pathology
and on the technological aspect of nursing, rather than on
nursing functions that stress the psychological and well-
rounded aspects of human care. Upon graduation most student nurses pursue paramedical studies in kinesitherapy , arts
and crafts therapy, anaesthesia, baby and child care, and
social work.
Postgraduate Education
The first French postgraduate school, tcole de
Cadre pour Infirmi^re , was started by the French Red Cross
in 1952. Such schools train nurses to become head nurses
for hospital units and nursing instructors. No out-of-
hospital cadre training is available "''^^ In 1965, the
International School for Higher Nursing Education was set
up under the sponsorship of the World Health Organization.
The school trains graduate nurses to take up supervisory
positions in hospitals or to become directors of schools
of nursing at the graduate or undergraduate levels.
Training for leadership in public health nursing was also
= 152- ; : offered by the school. 1 3 19 11
In 1967 France signed an agreement on Nursing Education and Training v;hich was the result of a simultaneous 95
action of the French National Nursing Association, the Inter-
national Council of Nurses, the International Committee of
Catholic Nurses and Social Workers, and the Western European
Group of Nursing. The agreement allows for reciprocal
acknowledgement of nursing diplomas and for free circulation of nurses between European countries '"^^ As a result of this agreement, France has witnessed what is called a French
Revolution in Nursing. Nursing students banded together
and founded their own council in an effort to bring reforms
in nursing education that included extending the period of
study to three years with more emphasis on the human being
rather than the almost exclusive emphasis on the ailment.
This movement, which took effect in 1972, focuses on inte-
gration of courses and continuity between theory and prac-
^^ce.^-'^^^ Psychiatric and public health nursing, the long forgotten fields of nursing in France, are also emerging to establish their own cadres and to claim access to basic training schools. At present the psychiatric nurse receives
,two years of ^ ' training . In France, public health nurses and social workers have always had combined jobs in what is called the Assistante Socials, whose training cov- ered the two years of study in a nursing school followed by another year and a half in a school for social workers. At present, the National School of Public Health offers a one-year program to public health nurses, social workers, and midwives who have a minimum of three years experience in
their own areas '"^ " -"-^^^ of specialization . ^
One level of nurse training is in existence at
present in France with the "Baccalaureat" as the acceptable
level for direct entry into the program. An examination at
the end of the first year is given before students are
promoted to the second year. The final examination,
completely under State control, is held once a year and
consists of written papers in medicine and surgery, a prac-
tical examination in the hospital, and an oral test.^''^"^^
Control of the State over nurse training, examination, and
registration has been complete since 1922. This is done
through an advisory council on nursing affairs appointed by
the ^ " Ministry of Public Health .
Midwifery has been completely separated from genera]
nursing and is regarded more as a general profession. The
training which takes place in schools of midwifery that
are generally attached to medical schools, covers three
years during which examinations are given at the end of 2 7 3 6 each ' year. Upon completion of training, midwives can set up their own practice or obtain a position in a mater- nity home, which is usually run by midwives and in which most of ^ ' ''^^ deliveries take place .
Health services have grown in much the same way throughout Western Europe. Social security, which was codified in 1945, covers the entire population. The system is presently self-supporting from contributions of employ- ers and employees. French people can recover as much as 97
75 percent of doctors' fees and sometimes as much as
100 percent is refunded if the illness is costly and lengthy. ~ The social security system retains the right of the person to choose the physician, chemist, hospital or nurse. 98
References
1 Badouaille, M.L. Present and future position of the nursing profession in France. International Nursing Review, 1970, 17, 1A6-57. (French)
2 Barrowclough, F. The French connexion— and nursing. ' Nursing Times, 1912, 68, 735-6.
3 Bullough, V. and Bullough, B. The eniergenoe of modern nursing (2x\d ed. ) . London: The Macmillan Co., 1969.
4 Burrus , 0. The nurse in 1976; who is she? Revue de L'Infirmiere, 197^ 20(4), 297-304. (French)
5 Chaptal, L. Nursing progress in F-^ance. American Journal of Nursing, 1929, 29, 807-10.
6 Cowen, E. The six: social services (part 3). Nursing Mirror, 1912, 134, 12-4.
7 Dock, L. Views of nurse training and reforms in French hospitals. American Journal of Nursing, 1903. 4, 61 235-9. ...
8 Dock, L. The revolution in French hospitals. American Journal of Nursing, 1905, 5, 428-30, 519-22, 693-8 887-9.
9 Dock, L. French nurse training. American Nournal of Nursing, 1906, 6, 316.
10 Dock, L. The Bordeaux School of Nursing. American Journal of Nursing, 1901, 8, 202-4.
11 Dock, L. The Florence Nightingale School in France. American Journal of Nursing, 1918, 18, 1168.
12 Dock. L. Progress in France. American Journal of Nursing, 1921, 21, 393-5.
13 Dock, L. Nursing in France. American Journal of Nursing, 1926, 26, 35.
Dock, 14 L. Nursing in Fra.ice. American Journal of Nursing, 1932, 32, 745.
15 Dock, L. and Stewart, I. A short history of nursinq. New York: G.P. Putnam's Sons, 1938. 99
16 Dolan, J. History of nursing (12th ed.). Philadelphia: W.B. Saunders, 1968.
17 Fautrel, F. France: Luxury and militancy. Nursing Times, 1973, 69, 13A3-6.
18 Goodnow, M. Nursing history (9th ed. ) . Philadelphia: W.B. Saunders, 1955"^.
19 International School for Advanced Nursing Education, Lyons, France. International Nursing Review, 1967, 14, 11.
20 Jameison, E. and Sewal, H. Trends in nursina history (6th ed.). Philadelphia: W.B. Saunders, 1966.
21 Jensen, D.M. Histon/ and trends of professional nursing. St. Louis: C.V. Mosby, 1955.
22 Sellew, G. and Ebel, E. A history of nursing (3rd ed.). St. Louis: C.V. Mosby, 1955.
23 Seymer, L. A general history of nursing. London: Faber and Faber Limited, 1935.
24 Stewart, I. and Austin A. A history of nursing. New York: G.P. Putnam's Sons, 1962.
I. CHAPTER 6
ITALY
Nursing in Italy, as in other European countries of
the era, was done by monks and nuns. Therefore nursing was
^ " • -^^^"^ controlled by ' ^ priests rather than by doctors .
Nevertheless, the servant nurses did must of the nursing
care and hospitals were staffed by cheap labor. ^""^^^ The
more technical and responsible parts of nursing were done
''"^ by doctors and . ^ medical s tudents ' Because of the fact
that the social restrictions surrounding young girls were more
confining in Italy than in France, attempts to establish a
secular nursing profession were met with great resistance.
The Nightingale's Influen ce
The earliest Italian pioneering nursing reforms
owed much to Florence Nightingale's influence. In 1895,
Amy Turton, a Scotch woman and resident of Florence, corre- sponded with Florence Nightingale on possibilities for reform in Italy.*^-^^^ She then spent a year as a paying probationer in the Royal Edinburgh Infirmary. Upon comple- tion of her training she decided her mission in life was to open the doors of hospitals to a new movement in secular nursing. With the help of some matrons, she succeeded in
100 101
opening the first school of nursing in Rome. She then
induced Grace' Baxter, bom in Florence of English parents
and trained at Johns Hopkins Hospital in Baltimore, to open
a school of nursing in Naples. Both schools started on a
small scale for lay nurses. The school in Naples, later
called the Blue Cross (Ci-oss kzzuvva) trained students who
took head nurse positions in various hospitals in
'"^"'"^^ Italy.^' Signora Celli, a German by birth,
helped the two women pioneers with her survey of Italian
hospitals in which she described and criticized the nursing
care done there. Celli wrote many articles and conducted
a woman's conference in which she call'Bd for nursing
. 16:154 reform.
Schools developed slowly in spite of the effort of
the two pioneers. This was partly due to prejudice among
the better class Italians against nursing as a profes-
'"^ '''^ " '"^"^ sion. ^ ' ' However, Amy Turton did not give up.
In 1910, she founded another school in Rome and put it
13 . • ^ -470; 16: 154 under the directionJ. of Dorothyr^ Snell.c TT ihis
school, later called Regina Elena, had the patronage and
interest of Queen Elena and the assistance and support of
the medical profession, thus becoming one of the leading
TO Q T 1 / schools of nursing in Italy. ~ On the whole little
reform in nursing education occurred before 1914, and all
schools had difficulty developing until the social structure
of Italy changed. 102
The Italian Red Cross
World War I brought with it the need for lay nurses.
This resulted in a change of attitudes and gave Italian
girls freedom to choose careers. Although attempts were
made in Italy before the war to organize nurses in an asso-
ciation, the few trained nurses who were available then and
the disinterest of the government resulted in fruitless
efforts. The war also brought the Red Cross into existence in Italy and later this organization, with the help of the
American Red Cross, undertook the task of promoting modern
-^^^ skilled nursing.^- Mary Gardner organized Public Health
Nursing with the help of the Italian Rod Cross Society.
Her movement attracted many young women into the profession
who hovered around the small centers she had established and tried to help in the organization as the war pro-
gressed. ; 13 : 470
In the years that followed the war, training schools were opened by the Italian Red Cross which offered two programs in nursing. One was an internship in which stu- dents lived in the hospital where they received practical training. The other was an externship where students stayed at home and hence received limited clinical experience. At the end of the two-year programs, students took a theo- retical test which allowed them to be admitted to a post- basic degree in Public Health Nursing . -"-^ • -^^'^"^ 103
At this stage the assistance given by the Red Cross societies to the development and reforms in the nursing pro-
fession in Italy was in the form of
(1) organizing a Corps of Voluntary Nurses which had a strong influence in raising the prestige of nursing,
(2) instituting professional schools for nurses at Milan, Rome, Bari, Bologna, Turin, and Parma,
(3) putting forward legislative dispositions con- nected with nursing,
(4) being the first to use nur-res in the public health field, and
(5) creating nursing services with the main objec-
tive of demonstrations and experiments . 18 : 1957
Nursing Decrees and Nursing Progr ams
Under the Fascist regime, the government became interested in nursing and moved to establish nursing stan- dards. As a result an Act was passed in 1925 V7hich
(1) recognized nursing as a profession,
(2) placed nursing edcation under the joint responsibility of the Ministries of Inter- ior and of Education,
(3) authorized the establishment of basic nursing schools and postgraduate courses in institu- tions to be approved by the two Ministries, and
(4) authorized the Ministry of Interior to make contributions for the functioning of these schools. 18:1958
In 1929, another decree was passed which regulated the governance of these schools This was followed by a third decree in 1938 which gave the exact content the schools had to adopt in their curriculum 18:1958 104
These government decrees resulted in the founding of the different types of nursing programs
(1) two-year undergraduate program leading to a professional State diploma in nursing,
(2) one-year postgraduate course for the training' of head nurses leading to a State certificate,
(3) one-year postgraduate course for the training of public health nurses leading to a State diploma in Public Health Nursing,
(4) a two-year course for the training of children's nurses leading to a professional diploma in
children' s nursing , and
(5) a three-year course for the training of raidwives leading to a professional diploma in mid-
8 : : wifery . 30 ; 18 1958
Nursing Organization and Legislation
Before the Act in 1920, a group of nurses had organized a National Association for Italian Nurses which was recognized by the Italian government at the time the
Act was issued. The plan then allowed nurses v/ho met requirements of the State diploma to join the Associa- tion. ' In 1933, the Fascist constitution in
Italy recognized State-registered nurses as belonging to a professional group rather than to a trade union. This was achieved through the strenuous efforts of the nurses' official organ, the Italian Nurse (L'Infirmiava Italiana) coupled with the support of the physicians and profes- sionals who believed in the advancement of nursing as a profession. 6^273;17:49-50 105
After the second World War in 1946, the Italian
Nurses' Association was admitted to the International Council
of Nurses as an active member with about 1000 nurses. '
Due to the stronghold of trade unions that supported prac-
tical and lay nurses who were abundant at that time, a law
was passed in 1954 whicli established a National Registration
Board for Nurses that placed nursing education and practice
^ " '''^ ^ under the Ministry of Health and Education . The respon-
sibility for the administration and supervision of nursing
education was then placed in the hands of the High Commis-
sariat. A post of nursing inspector was created in 1940
for nursing schools and services. A professional nurse was
appointed to this position. Public health nurses were
employed by the Commissariat in various sections of public
18 • 1959 health service.
The consequence of the Strasbourg conference in 1967
was the formulation of standard programs of nursing among
the European countries. This was intended to allow for free
: mobility of nurses among the different countries in Europe
as well as the establishment of a program to meet the
country's needs and at the same time fall within the stan-
""-^^^ . -"-^ • '^^ • dards set by the conference '
Nursing Education
The training of a nursing student at present lasts
for two years and takes place in a "Convitto" where students
live. The minimum age of entry is 17-18 years V7ith secondary 106
'^^^ ^-^"^ education ' as a requirement for admission. •
Some nurses are paid small wages during the period of
training. Lectures are mainly given by physicians and
tutorial nurses while clinical experience is left mainly to
the nursing staff on the wards. The final State examina-
tion is given at the end of the two-year training period.
It consists of a written and a practical part and an oral
examination conducted by doctors. The title Infirmiera
Professionale, which is equivalent to an SRN is given to
. "'"'^^"^ students who pass '
One year of formal training is nov/ available for
practical nurses. Courses are organized by hospitals and run by doctors. Applicants to these programs com.e mainly
from domestic aides v7ho are currently working in some hos-
pitals in Italy. Still little difference exists between the work done by a State Registered Nurse, and that of a
nonprofessional. '
Schools of nursing in Italy at present are like the
pendulum, pulled by two main forces: the evergrowing
national need for more nurses at any level of education, versus the long-range plans of nurse-educators for a more
comprehensive program in nursing for the future. Appre- hension runs high at present concerning the educational preparation of nurses that does not meet the country's needs. This has brought out the importance of a sound preparation of nurse- teachers as a remedy to the perplexing 107
problem. The organization of university programs to prepare nursing educators is a major trend in the development of nursing in Italy. Emphasis is put on proper selection of
students to such programs to have participants dem.onstrate 1-124 proper attitudes as well as educational capabilities. 108
References
1 Andreoli, E. Nursing education today. Professioni Infermieristiche, 1976^ 28(4), 121-4. (Italian)
2 Armstrong, F.M. The Italian hospital and nursing. American Journal of Nursing, 1902, 2, 392-5.
3 Baxter, M. A letter from Italy. American Journal of Nursing, 1903, 3, 737-8.
4 Cioni, V. Italy: Hot temper and cold baths. Nursing Times, 1973, 89, 1382-3.
Di 5 Targiani-Guiunti , M. Notes on the history of nurs- ing care with a special reference to Italy. Interna- tional Nursing Review, 1957, 4, 12-5.
6 Dock, L. and Stewart, I. A short histury of nursing. New York: G.P. Putnam's Sons, 1938.
7 Enriques, B. Les infirmieres prof essionelles en Italie et leur preparation. Interytational Nursing Review, 1957, 4, 15-8. (French)
8 Fitzgerald, A. Congratulations to Italian nurses. American Journal of Nursing, 1926, 26, 30.
9 Goodnow, M. Nursing history (9th ed.). Philadelphia: W.B. Saunders, 1955.
10 Gubert, S. Nurses in Italy. Nursing Mirror, 1975 140(4), 63-6.
11 Huttenback, M. A semester in Italy. Nursing Forum, 1966, 5, 74-83.
12 Jameison, E., Sewall , M. and Suhrie, E. Trends in nursing htstory (6th ed.). Philadelphia: W.B. Saunders, 1966.
13 Jensen, D.M. Histoinj and trends in professional nurs- zng. St. Louis: C.V. Mosby, 195 5.
14 Nutting, M.A. and Dock, L.L. A history of nursing (vol. 4). New York: G.P. Putnam's Sons, 1910.
15 Saunders, R.G. Nursing and social services in Italy. Nursing Mirror, 1947, 85, 193-5.
16 Seymer, L. A general history of nursing. London: Faber and Faber Limited, 19 35. 109
17 Sgarra, A. Oganization of the nursing profession in Italy. I nternationul Nursing Review, 1955, 2, 48-54.
18 Sgarra, A. The nursing profession in Italy. Nursing Mirror, 1957, 205, 1957-9.
19 Stewart, I. and Austin, A. A history of nursing. Philadelphia: Putnam's Sons, 1962. CHAPTER 7
GREECE
Early Nursing in Greece
In Greece the transition from medieval to modern
professional nursing was brought about by Roman Catholic
and Eastern Orthodox religious orders and later through
"'"^ the influence * of the Red Cross . Some changes were
effected by deaconesses but carried little significance
because of the relative unimportance of Protestantism in
Greece. Late in the nineteenth century, Queen Olga took
an interest in nursing and established a two-year training
school for nurses. In 1885, the Evanghelismos hospital was ^ founded for the ' -^^^ training of s tudents . Queen Sophia
had a similar interest in the profession and hence in 1914,
a two-year training school was established for student
. volunteers and put under the direction of the Red Cross " '^'^
Graduates of these schools contributed to the establishment of the Greek Red Cross School of Nursing and Public Health
Nursing in Athens in 1924.^"^^^ As the above comments suggest, the profession of nursing in Greece owes part of its development to the vital support of the Royal family. Public health work started in Greece as early as 1919 and took place in baby welfare stations under the auspices 110 .
Ill
of the patriotic League of Social VJelfare and Assistance 9 2 242 • • 947 and with the help of the American Red Cross. '
In the beginning the workers were volunteers but upon
establishment of the Greek Red Cross School of Nursing, more emphasis was put on the training of public health 2:242 nurses
The Red Cross School of Nursing was the first school
in Greece that was founded on a modern basis by operating
a three-year program, a time frame thrt was internationally
3* 316* X6* 1_A2 accented at that time. " ' ' Student nurses, who numbered about 30 each year, took the school's final exam-
ination, which was virtually a State examination. The school was directed by Athena Messolora, a Red Cross graduate who
had taken a postgraduate course in public health nursing in 3*316 London. " Her contributions to the development of nurs-
ing in Greece and her leadership roles as a school director make her professional career an outstanding one in the
A • 7 nursing history of Greece. '
; The Kokina School of Nursing at Piraeus was started
in 1927 by the American Women's Association and was attached
to the American Women Hospital ."'"^ It offered a three-year
course in nursing under the administration of the American-
Trained Nurse, an Association of American nurses in 3*316*16 1^2 3 ' Greece. ' ' Students of this school, who were mainly refugees from Asia Minor, took the same final exam-
""-^ '^^"^ ination that the Red Cross School of Nursing of fered. • 112
Only 27 nurses were graduated from this school before it
had to close in 1933 for lack of funding and facilities.
The Near East Foundation in its program, on rural and
refugee camp work in 1930 trained many women in home hygiene
and care of the sick. Trainees from this program did excel-
lent work in helping during wars and in combatting infectious
. "^'''^ diseases in peacetime '
Four graduate nurses from the Greek Red Cross School
of Nursing helped in the reorganization of the Evangelismos
Hospital School of Nursing and as a result of their efforts
the school started a three-year course for nurse training
in 1930. In 1935, the Model Health Center was estab-
lished following an agreement between the City of Athens,
the School •'"^ of Hygiene, and the Rockefeller Foundation .
The Center was intended to be a training as well as a demon-
stration health facility for public health students, and for
student nurses in the Red Cross and the Evangelismos Hospi-
tal School of Nursing. Students were required to spend two
-months at the . center as part of their training " A six-
months postbasic course was as well offered by this facility
for graduate nurses who wished to work in the community.
With the outbreak of the second world war, the center had to suspend operations.
An institution which combined hospital and public
health nursing within a three-year period was established
in 1938 and was known as the State School of Nursing and '
113
Public Health Nursing. Students joining this program were
subjected to . university entrance requirements ' Since
1948, and by a Royal decree, all students entering the
three-year program in a school of nursing must meet the
same miversity entrance requirements .
In 1946, a military nursing school with a three-
year program was established to meet the army nursing needs.
Also, the old Greek Red Cross Volunteer Nursing School was
still active in preparing volunteer ni:rses in a six-month
course to serve in war or natural disasters. Schools for nurses aides, public health, and practical nurses were
started during the war in an attempt to meet the evergrowing
country's needs for nurses. After the war only three schools with a one-year training program were still train- ing the practical nurses who were functioning in hos- pitals.^=52-3
Nursing, Education in Greece
The overall nursing education program in Greece follows requirements set by the Ministry of Health for all '^•^^ schools of nursing. The basic and fundamental objec- tive is the correlation of theory with practice. Students get their theoretical instruction in medical and surgical nursing, obstetrics, pediatrics, psychiatry, and public health nursing at the time they are receiving their clinical experience in the corresponding fields in various hospitals .
114
and public health agencies. Public health has been inte-
grated in all the courses throughout the students' expe- 10-29 rience. The education of raidwives is conducted
separately in Greece. At present three schools for mid-
5 • 8 wifery offer three-year programs. '
Students in all schools of nursing pay no tuition
fees, since all education is free in Greece. They receive
free board and lodging, but they do not receive stipends.
All students have to sit for a final oxamination conducted
by their respective school's examining board. No State
examination is available; however, the diploma is confirmed
by the Ministry of Social Affairs and the new graduates are
registered in the Nursing Education Department of the Min-
istry. To be licensed, all registered nurses in Greece
must serve for three years after graduation in a State
. 12:29-30 institution.^.^ ^.
Today, nine schools of nursing exist in Greece,
three of them having a combined program of general and
: public health nursing. Of the nine, foar are independent
institutions affiliated with various health agencies in
order to provide field experience for their students,
while the rest are attached to hospitals. Eight of these
schools are located in Athens and one in Tnessalonika
Three are State schools, one is operated by the Red Cross,
one by the Patriotic League of Social Welfare, and four by ll:25-6;12:31-2;13:140-2 hospitals. 115
Nursing Organization
In 1923, the Hellenic National Graduate Nurses'
Association was founded in Greece through the efforts of
11 nurses who were trained abroad. Later, graduates of the
Hellenic Red Cross School of Nursing joined the Association, which became a member in the International Council of
Nurses in 1929. The Association presently edits a bimonthly nursing journal, Hellilis Adlphhi (Hellenic Nurse), which
is active in raising the standards of nursing in the coun- 11:28;12:35 try. '
Nursing Legislation
The first nursing section in the Ministry of Social
Welfare was established in 1947 with Helen Petralia as
11 2 8 chief nurse. ' Recognition of the Nursing Bureau at the
Ministry by the Parliament took place in 1948 and a Nursing
Legislation Act was passed which placed nursing education
11 "27-8 and registration under its supervision. ' Nursing as
a profession was given its rightful place, then, among other
professions. Graduate nurses were recognized by law as
First Level Civil Employees which at present grants them
equal rank with all other university graduates. The Bureau
developed a unified educational program and supervisory
committees were set to check if schools of nursing were
carrying out the right schedule of study. The Nursing Bureau,
in addition, defined conditions of service, rank, promotion,
and salaries, all major issues facing nurses at the time. Carr, A. Nursing in pre-war Greece. American Journal of Nursing, 1?42, 42, 370-2.
Dock, L. and Stewart, I. A short history of nursing. New York: G.P. Putnam's Sons, 1938.
Griffin, E. and Griffin, J. Jensen's history and trends professional of nursing. St. Louis: C.V, Mosby , 1969.
Ledakis , S. Nursing education in Greece. International Nursing Review, 1957, 4, 49-54.
McCarrick, H. Aristotle's midwife. Nursing Times, 1970, 66, 1470-1.
Messolora, A. Some aspects of nursing in Greece, American Journal of Nursing, 1940^ 40, 635-6.
Messolora, A. Athena Messolora. International Nursing Review, 1965, 12, 70-1.
Nicolo, S. O.R. nursing in Greece. AORN Journal, 1974, 19, 114-20.
Noyes, L. Establishment of foreign training schools. American Journal of Nursing, 1919, 19, 947-8.
Papamicrouli , S. The Greek Red Cross School for nurses and public health nurses. International Nursing Review, 1963, 10, 29.
Papamicrouli, S. Nursing in Greece. International Nursing Review, 1967, 14, 25-8.
Papamicrouli, S. Hellenic Red Cross School of Nursing: A combined program in general and public health nursing. International Journal of Nursing Studies, 1969, 6, 27-35.
Papamicrouli, S. Nursing in Greece. Journal of Psychiatric Nursing, 1969, 7, 140-2.
Rosaria, L. Nurse and child in Greek life. Journal of Pediatrics , 1947, 30, 205-213.
Sellew, G. and Ebel, E. A history of nursing (3rd ed.) St. Louis: C.V. Mosby, 1955. 117
16 Seymer, L. 4 general history of nursing. London: Faber and Faber Limited, 1935.
17 Smith, M. American public health methods in the Near East. American Journal of Nursing, 1928^ 28, 463-5. CHAPTER 8
NORTHERN EUROPE
The Deaconess movement of Kaiserwerth, Germany, influenced nursing in Norway, Sweden, Iceland, Denmark, and Finland, as it did in all countries where Lutheranism became dominant after the Protestant reform. "''^ ' '^''^
When the Red Cross prepared for hospital nurse training in 1864 in Northern Europe, its promoters looked to Florence
Nightingale for advice. As a result, a Swedish student,
Emmy Rapp was sent to St. Thomas's School of Nursing for training. On her return to Sweden she directed the schools of nursing in Red Cross hospitals. Emmy Rapp was regarded as Sweden's first trained nurse and a path breaker for many "^^^ others who followed. ^ '
Since a similar pattern in nursing development and practice exists in Northern Europe, special reference will be made on Sweden only with the hope that the reader will transcribe the development of nursing in this country to other Scandinavian countries in the region.
118 '
SWEDEN
Systematic training of nurses began in Sweden in
1884 and arose on the initiative of Queen Sophia, who
cherished a desire to provide regular instruction in 13 237-8 nursing based on Christian principles. ' This
brought about the foundation of the Sophia Home or the
Sophiahemmet Hospital in 1889 which offered a training
2 ^ . gQ course in nursing to selected candidates. ' In 1901,
the South of Sweden Nursing Home was opened to train nurses
1 3 2 3 8 for hospital and private v7ork in southern Sweden.
The Sophiahemmet was built primarily to give nurses a
source of practical training and at the same time a house
for their residence during the two-year training period.
Student nurses received no stipends. They were required
to pay tuition for their training, an uncommon situation
' -'"^^^ "'^ ^"^^^ ^ ' • in Europe at the time . In 1905, most schools
"'"^ ' ''"^^^"^^ were offering a three-year course in nursing .
State Involvement
Up to 1920, the State took little interest in nursing but in that year Parliament passed several acts which provided State registration of nurses. State super- vision of nursing education, and S tate- controlled employ- ment bureaus for nurses. This action proved to be
119 .
120
successful from the viewpoint of the public and the nurse,
. . 2-1337 giving protection to both. ' A nursing division was established at the same time under the Royal Board of
Health with Kerstin Nordendahl, a graduate of the Sophia- hemmet, as its head. As a result, many small nursing schools had to close for they did not fulfill the require- ments set by the Board. Also, no school could be opened without a permit from the Board. In addition, the teaching plan of every school went to the Board for approval and from then on the institution remained under State super-
. . 2:1337-8 vision
Nursing Association
The Swedish Nursing Association, which was founded in 1910 with Emmy Lindhagen as first president, was con-
1 2 cerned mainly with developments in nursing education.
The question of salaries and working conditions was left to the Nursing Bureaus. Since 1917, postgraduate courses in hospital administration and teaching have been offered 2 • 13 38 by the Association. • In 1933, the Association adopted the Swedish ^.Journal ^ '"^"^^ of Nursing as a private enterprise . "
In addition to the work put toward the development of nurs- ing to best serve the needs of all the people, the Swedish
Nurses' Association takes an active interest in legislation affecting hospital construction and in vocational guidance.
It is also influential in matters of general education and 121
social issues which were supported by Gerda Hojer, a Swedish nurse of international reputation who served as the presi- .^^'^^^ dent of the International Council of Hurses in 19^7
Because of the similarity of the Scandinavian languages, Nordic Congresses could be established, litera- ture exchanged, study tours arranged, and nurses interchanged between hospitals of the different countries. This has kept the various nursing associations in close contact with each other and has led to development of a regional organization known as the Association of Northern European Nurses. It meets in convention every four years. This allowed for more exchange of ideas and developed interest among student
^^'^ nurses of one country to take nursing courses in another
The Swedish Federation
In January 1965, a new Federation was organized in
Sweden on the initiative of the Swedish Nurses Association.
This newly founded association was called the Swedish
Federation of Salaried Employees in Hospital and Public
Health Services, which included, besides the Nurses Asso- ciation, the Laboratory Technicians Association, and the Medical Technology Association . The main task of the
Federation was to work for improved salary and employment conditions and to support tne newly developing fields in technology in legal matters until they could stand on their
^ : own • 16:35 feet. Swedish Nurses' Association has .
122
a long history of continuous effort in the development of
bargaining rights for nurses and others belonging to the
Federation. Much of the collective bargaining done in
Sweden then was based on practice rather than legislation
until 1936 when a law was passed which recognized the
Association as the negotiating body between employer and
employee. Since 1966, all public service officials are
covered by an Act which allows for nurses to resort to
strike action if negotiations fail.'^"^,^
Nursing Education
All activities in the fields of Public Health and hospital care in Sweden are either operated or controlled by public authorities. The Ministry of Health and Social
Affairs is responsible for the health services at the governmental level. The National Board of Health and
Welfare governs, superintends, and promotes the activities and work of the institutions in the field. In other words, the Board supervises the medical personnel, the hospitals, and the pharmacies and grants licensure to physicians, registered nurses, midwives, and other medical person- 17:340 neir,oi
Before 1968, all nurses went through a three-year education program which included a certain amount of specialization in one or two branches given in the third year of study. In 1966, nursing education was recognized and a new curriculum was established comprised of two and 123
a half years of study, at the end of which registration
could be achieved. The program provides the students with
a broad educational background in nursing, at the end of which they are qualified as general nurses in any hospital.
Specialization is now offered after registration and fields such as pediatrics, operating room, and midwifery are now available.
Sweden has 34 nursing schools which are organized the same way and have the same syllabv^s and curriculum.
Nursing education at present is free of charge and nursing students receive scholarships and financial aid from the ^^^"^ government. '^^ The trend now is to set up combined schools for various training in the health field, for example, basic nursing education, postbasic nursing education, practical nursing education, nurses' aide educa- tion. X-ray and laboratory technician education and others.
Many schools of nursing are presently housed in such facil- 17=342 ities.
Requirements for admission to a school of nursing include a minimum age of 18 years and the completion of grade nine of the compulsory school leaving certificate. The length of basic nursing education is five semesters of
21 weeks each, during which theory and practice in medical- surgical, pediatrics, obstetrics, public health, and psychiatric nursing are given. A diploma is awarded at 124
the end of the program which entitles the nurse to State
. 17:343 registration., ^.
In 1968, a general pattern of postbasic education was proposed in a government bill which established cur- ricula in different fields in a program of one or two semesters long depending on the specialty. These curric- ula are established for the following fields of study:
Medical and Surgical Nursing 1 semester
Geriatric Nursing 1 semester
Psychiatric Nursing 1 semester
Anesthesiology Nursing 2 semesters
Operating Room Nursing 2 semesters
Intensive Care Nursing 2 semesters
Pediatric Nursing 2 semesters
' Maternity and Gynecological Nursing 2 semesters (Nurse-Midwifery)
Public Health Nursing 2 semesters
The aim of the program is to prepare professional nurses
for leadership positions. Requirements for admission
include State registration and an employment period that
ranges between six months for all the fields and two years 17:344;21 for publicUT healthu i^u nurses.
Advanced nursing education is offeied at the State
Institute of Advanced Nursing Education headquartered in
Stockholm and four other branches in different parts of
the country. Courses in nursing education are 56 weeks )
125
long, and nursing service administration covers a AO-week period. Requirements for admission to both programs include state registration, two years of experience, and meeting the university entrance requirements "^^^
Training for practical nurses was started in 1962.
The practical nursing course requires 32 weeks, or 23 weeks if the student has at least one year of experience as an aide. A course for nurses' aides is also offered and is
. ''"^ '^^"^ 23 weeks long with no educational requirement '
Practical nurses in general hospital wards, operating rooms or outpatient departments may take up registered nurse training in a course that has been shortened from five semesters to three semesters, acknowledging their previously 2 A acquired knowledge. (See Figure 2 .
I. Midwifery training in Sweden is changing to fit in with the new general nursing scheme. Student nurses in midwifery are required to complete the two-and-a-half year training course before they go into midwifery. Training will then take one academic year during which many medical procedures are practiced. At present, two midwifery schools are available in Sweden for the national policy is to
'^^ ' ''^ centralize courses .
The health visitor and the district nurse in Sweden are one person.^ Two public health nurse- training centers are in existence today in Sweden. Students receive State grants during their training and work alongside the physicians ^ ^ ^ \ — ' —
126
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(U CM H -H 4-i CO o X CO •H •H o OJ > •• 60 4-1 u CD d CO d o u •H cu CO E •H •H o CO txO O UH 4-) X) CO cu ^1 o u D. (U CU 14H 3 Q) u CO a o x; u M 0) M-l •H 00 -o d (-1 X) ^— cu u C B a-r-i cd cd < H CO cu CO CO CO X) 0) i-l OJ -H 6 3 rH - — O o CO d C. cn o d OJ cu nes u •H CO cu CO p. (U CO cu tic hOE Id
Although little public health nursing is available in
Sweden compared with that offered in other countries, home
helps are always available to families in need of such
services. These are available through the training of
women as home nurses who are constantly supervised by the
few public health nurses present . ''"'^ '
Health Care in Sweden
In Sweden the main administration of the health care
services is under the control of the local authorities—
the Regional Councils — that are responsible for the planning,
and day-to-day financing and organizing of hospitals.
A three-tier structure is characteristic of health and medical services there. The emphasis is on intermdiate
care at the community level; this was felt to be an economy way of providing better care to the patient. The emphasis on hospital care now is decreasing and the patient is more
and more oriented to the local health center that usually has general practitioners, nurses, social workers, and sometimes specialists who offer individualized patient care. Localized personal documentation ensured that documents are easily available, an important aspect of community care that saves time, transport, and travel, and provides a better and more personal service to the indi- vidual.6=66-7
An important feature of the Swedish health centers is their attachment to nursing homes that treat chronically 128
and physically sick patients. Some health centers are
deeply involved in research besides providing personalized
care to patients. Others are attached to hospitals that provide specialist outpatient care as a measure to take
the burden off the hospital and outpatient department in offering specialist advice and care.
The existence of the health center as offering specialized care has contributed to the development and
the expansion of the nurses' role. Nurses are given special local courses in different specialty areas such as diabetes and tumor, and are asked to attend medical- student classes at a local university before taking over the management of the specialty clinics. The nurses are responsible for the medical history, physical examination, assessment of the patient's condition, and follow-up care.
The doctor checks on the patient once a year only, and when the patient is referred to the physician by the nurse^.'^''
This new role is welcomed by the nurses in Sweden as well as by other authorities that are demanding more specialization and training of nurses.
All the rest of the Northern European countries enjoy a socialized health care delivery system which is more or less similar to the Swedish. The development of nursing in all of them follows a pattern. All countries share a common belief that the function of the profes- sional nurse cannot remain static. Qualified nurses are 129
expected to have more technical and specialized responsibil- ities when working in specialized units. This trend is hoped to bring with it some change in the expanded role of
the nurse.
Community Nursing in the Health Care Delivery System
A modern care deliverj'^ system requires for its
functioning a trained body of health professionals. When
the health needs of a society change, a mechanism should go into operation provoking a rearrangement of the work done by the different professionals. This should also be accom- panied by a change in the educational system to adapt the
training of the different kinds of the health professionals.
An asset to such a change is the need for an interaction between the educational and health care delivery systems of 18:31 the coimtry.^
In October 1974, a shortage of public health personnel existed in Sweden including doctors and public
2 A- health nurses. However, the number or nurses has increased
considerably since then, especially in the public health section. Community health nursing seems to be the trend in
Sweden. This group of professionals carry on outpatient work outside the hospital. Their functions include preven- tive health care, medical care, and sociomedical care.
At present 3000 community health nurses and 400 district midwives are employed in the Swedish community services. 130
These employees have three years of undergraduate nursing,
two years of practical experience, and one year of special-
. . 3-1 ization training.
Community health nursing in Sweden forms a ; major part of the primary care delivery system. The goals of this
system are to provide
(1) a total view of the patient,
(2) local service, easy access,
(3) continuity,
(4) reliability and quality of care.
These points are enhanced by teamwork and by interaction between different branches of the health service. The
duties of the community health nurse deal with
(1) preventive health care,
I (2) curative medical care,
(3) sociomedical care,
(4) administrative and other duties.
These tasks are expected to increase as new techniques and
facilities are developed in the health care arena.
The organization of the community health work is
divided among
(1) community health nurses,
(2) midwives in maternal health care,
(3) nurses in child health care,
(4) physiotherapists and occupational therapists in primary care. .
131
(5) junior nurses and nurse' aides,
(6) office clerks,
(7) district medical officers,
(8) social workers,
(9) domestic aid supervisors.
Organizationally, community health nursing should be built around the largest health care center in the primary care area where smaller centers could be attached for local 3:4 service
The health delivery system in Sweden functions as an organic whole, with a defined relation between its dif- ferent institutions and levels of medical care. What is more unique of such a system is the fact that the local communities direct practically all of the system through a decentralized regional organization, and the overall national coordination is achieved by voluntary contact and orderly advice from government officials but with little government domination. 132
References
1 Adler, S.P. Swedish student nurses: A descriptive study. 363-5. Nursing Eeseurah, 1969 , 18,
2 Andrell, N. Nursing in Sweden. American Journal of Nursing, 1940, 40, 1336-41.
3 Axelsson, S. and Nicolausson, U. Community health nursing - Farthest outpost of the health and medical services. Current Sweden, 1977, 144, 1-7.
4 Bergkenst, G. Collective bargaining in Sv/eden. International Nursing Review, 1968, 15,
5 Berglind, H. Occupation activity of a Swedish RN. International Journal of Nursing Studies, 1965, 2, 251-60.
6 Cawford, L. Health care in Denmark, S\.eden, and Holland. Nursing Mirror, 1975, 141(14), 65-7.
7 Dock, L. and Stewart, I. A short history of nursing. New York: CP. Putnam's Sons, 1938.
8 Dunbar, V. Nursing in Northern Europe. American Journal of Nursing, 1937, 57, 123-30.
9 Hjern, B.O. \"Jhat about socialized medicine in Sweden. Archives of Surgery, 1976, 111(9), 941-4.
10 Hooper, J. Nurse training in Sweden, 'Aug. 1968. Nursing Times, 1969, 65, 73-6.
11 Jameison, E. and Sewall, M. Trends in nursing history (6th ed.). Philadelphia: VJ.B. Saunders, 1966.
12 Nordendahl, K. Nursing in Sweden. American Journal of Nursing, 1948, 48, 694-6.
13 Nutting, M.A. and Dock, L.L. A history of nursing (vol. 4). New York: G.P. Putnam's Sons, 1910.
14 Olsen, M. Nursing in Sweden. American Journal of Nursing, 1932, 32, 1059-63.
15 Peck, L. Psychiatric nursing in Sweden. Nursing Mirror, 1969, 129, 27.
16 Rabo, M. Sweden initiating a new Federation. Inter- national Nursing Review, 1965, 12, 34-6. 133
17 Rabo, M. Nursing in Sweden. International Nursing Review, 1911, 18, 334-48.
18 Rexed, B. The role of medical education in planning the development of a national health care system. Journal of Medical Education, 49, 27-42.
19 Sellew, G. and Ebel. E. A history of nursing (3rd ed.). St. Louis: C.V. Mosby, 1955.
20 Setzler, L. Stockholm diary. American Journal of Nursing, 1946^ 46, 46-7.
21 Swedish Board of Education. The postbasic nursing edu- cation in Sweden, 19 70. Unpublished manuscript. (Available from the Royal Swedish Embassy, Washington, D.C.)
22 Swedish Board of Education. Training of auxiliary nursing personnel, 1974. Unpublished manuscript. ^Available from the Royal Swedish Em.bassy, Washington,
23 Swedish Board of Education. The basic nursing educa- tion in Sweden, 1975. Unpublished manuscript. (Avail- able from the Royai Swedish Embassy, Washington, D.C.)
24 Swedish Institute. The organization of medical care. I, Fact Sheets on Swede>i, 1976.
25 Wald, L. The Sophiahemmet in Stockholm. American Journal of Nursing, 1900, 1, 180-2. CHAPTER 9
YUGOSLAVIA
Yugoslavia is a Federation comprising the Republics
of Serbia, Croatia, Slovenia, Montenegro, Bosnia, and
Macedonia. The country has existed as a geographical and
political unity since 1918, prior to which the Republics were separate kingdoms. This has contributed to the fact
that nursing in Yugoslavia has developed along unique lines.
The first developments in nursing are traced to 1856 when
the government gave an order that all care of the sick in hospitals was to be undertaken by the Sisters of Charity
This important event affected the development of nursing in
the different Republics.
Early Nursing Practices
Except for the building of hospitals and the transfer J of the sick from monasteries where they received treatment, no significant changes were noted between 1856 and World
War I. At the end of the war, the revival of nursing and medical practices came about as a result of war experiences and activities. ' Numerous health centers were opened by the government to meet urgencies of postwar conditions.
In 1919, the Slovania Faculty of Medicine was founded by
134 .
135
the University of Ljubljana which had important influences on the health services of the area. The same period also witnessed the arrival of the first registered nurse, Slovina
5 236 Angela Boshin from Vienna. ' Having been educated in
Vienna under the Blue Sisters, she came to Yugoslavia to start the hard elementary work in the establishment of district nursing and social health. In 1924 a district nursing school was opened which began by offering a one- 7-152 year course. ' Two other schools of nursing were estab- lished at about the same time. One is the Belgrade Train- ing School for Nurses which was started on the English plan in 1921 by Emid Newton. The other was the State School of
Zaghreb which trained students from both religious and
, 5:236-7 secularT orders
' During the organization period in Yugoslavia, nursing had the support of Dr. Andrija Stampar, Director of Health and one of the outstanding public health leaders of Europe.
His interest in community health was reflected in the train-
ing of public health nurses of the different schools.
Because of Dr. Stampar' s interest in welfare institutions, all schools of nursing and health centers stressed the
' ''"'^^ ^ " ^ concept of preventive care . '
Development of Professional Nursing
Professional nursing went through a relatively slow
development until 1945. However, after World War II, nurs-
ing developed rapidly. Factors that influenced its progress 136
were the shortage of nurses during and after the war and the rapid development of the country's health services with an
''"^ increase in governmental interest in nursing . ' In each of the separate Republics, councils of health and social policy were established which were responsible for setting up schools of nursing and determining the regulations under
'^^ ^ which they had to be conducted. ' As a result, three types of schools were started which varied in academic level, admission requirements, and length of the course. An advanced school of nursing offered a three-year program and required applicants to meet the university entrance require- ments. A middle medical school also offered a three-year program but admitted students with only four years of high school. The last offered a program which also required
n . c 1 7 students to have completed four years of high school.
The advanced schools of nursing were established in
1951. The one in Belgrad was administered by the Red Cross
Committee of Yugoslavia. The curriculum of all schools of nursing prepared students for both hospital and public health
9 5 8 7 work. Until 1950 no postgraduate course of study was available to graduate nurses in Yugoslavia except for the programs offered at the schools for midwives . But since then postgraduate courses have been offered in teaching, head- nursing, operating room nursing, nurse dietetics, and public health nursing. 137
Nursing Association
The Nurses' Association in Yugoslavia is a Federation
of Nurses' Association of the Republics of Slovenia, Croatia,
Macedonia, and Serbia. The Yugoslavian Graduate Nurses'
Association was established in 1926 by the graduates of the
first school of nursing in Zaghreb and in 1929 the Associa-
tion became affiliated with the International Council of
Nurses. In 1931, an Act signed by the king provided for the
three-year curricula, set standards for admission, provided
for proper selection and organization of nursing faculty,
/; Q . T 9 _ o and defined the status of nurses.
After the second World War, the nurses in each
Republic began to reform their own branches of the Associa-
tion. The Federation was admitted into membership with the
International Council of Nurses in 1957, for it dropped out
•'•^^ • -^^^ after the ^ ' ' ^ Communist revolution . The different
Associations were active at the district level where sem-
inars, refresher courses, and postgraduate programs were
offered to nurses in different fields.
Nursing Education
A brief explanation of the general education system
in Yugoslavia may be helpful in understanding the nursing education system. All students in this Eastern European country attend elementary school for eight years. Then they
"^^y enter a four-year middle school which combines general education with training for a technical, vocational, or )
138
semiprofessional career. Basic nursing education is included
in this program. On the other hand, students may choose to
enter a four-year academic school (Gimnazija) at the comple-
tion of which they can enter the university or an advanced
school that prepares them for special careers . The three-
1 36 - year advanced nursing course is included in this program.
(See Figure 3.
In 1963, the Advanced School of Public Health was
established by the Yugoslavia Red Cross Society. It trains
teachers and administrators for public health leadership
positions in a two-year program. To be admitted, a student
should have completed the middle-school nursing program and
should have worked as a nurse for at least two years. '
Training for midwives and pediatric nursing is
available in Yugoslavia at present and the program covers
four years. Middle school nursing is now expanded to cover
four years instead of three. Many advanced schools that
require applicants to meet university admission standards
;have been established and are gaining in popularity.
A program that offers a two-year course to train assistant
nurses, whose duties are simlar to those of licensed prac-
tical nurses in the United States, is now available also.-'-'"^^
Schools of nursing at all levels are approved by the Coun-
cils of Health in each Republic. In addition, a State
examination is set by the Central Council of Health; the
grading of the salary scales is dependent on the passing of this examination. ' 139
Elementary School Education 8 years
Secondary School Education Secondary School Education 4 years 4 years General Education & Tech- Academic; prepare for nical, Vocational, etc. University admission
"Middle Medical School" for basic nursing preparation "Gimnazija"
2 years work experience as a graduate Advanced School (of
nurse nursing) - 3 years basic nursing educa- tion
Advanced School of Public
Health Nursing - 2 years Post-basic nursing education
University
Figure 3. Nursing Education in Yugoslavia.
From: Benson, E. Vignette of nursing in Yugoslavia. Nursing Outlook, 1969^ 17, 36-8. 140
Since a great similarity exists among the Eastern
European countries, the reader will find them operating more or less along the same line. Differences do exist, however, between those countries and the western world,
.1. which have their roots in Communist patterns that dominate the health care delivery system in Eastern Europe. In spite of the restraints, Yugoslavia and Poland have shown greater initiative than other countries in the area, in their attempt to unite with nurses in the world and in the improvement of nursing education and service.''""'"
The summary of nursing education in Yugoslavia can perhaps best be illustrated by the accompanying chart. 141
References
1 Benson, E. Vignette of nursing in Yugoslavija. Nursing Outlook, 1969/ 17, 36-8.
2 Benson, E. Nurse to nurse contact on the international scene. International Nursing Review, 1971, 18, 281-6.'
3 Benson, E. Nursing in Serbia . . . early days. American
Journal of Nursing , 1974, 74, 472-4.
4 Bridges, D. Yugoslavija. International Nursing Review, 1959, 6, 23-7.
5 Dock, L. and Stewart, I. A short history of nursing. New York: G.P. Putnam's Sons, 1938
6 Ingram, R. Nursing in Yugoslavija. American Journal of Nursing, 1930, 30, 139-45.
7 Slovenija, S.E. The development of nursing in Northern Yugoslavija. International Journal of Nursing Studies, 1972, 9, 151-8.
8 Some impressions of nursing in Yugoslavija and Hungary. American Journal of Nursing, 1931, 31, 671-6.
9 Stewart, I. and Austin, A. A history of nursing. New York: G.P. Putnam's Sons, 1962.
10 Urbancic, D. Nursing in Yugoslavija. ' American Journal of Nursing, 1956, 56, 585-7.
11 White, K.L. International comparisons of medical care utilization. New England Journal of Medicine, 1967, 277, 516-22. .
CHAPTER 10
RUSSIA
Russia is a country that had its own originality put into the development of the nursing profession.
Whether it was ever influenced by the British system is
doubtful. The Soviet Union had Sisters of Mercy as far back as the Crimean War but they were not of the same type
^ ^'^^ as the religious orders of the Catholic countries . '
These sisters were voluntary workers who came from upper
, 6: 240; 20: 345 class families^ or were widows of^ army officers
In Russia, the Red Cross was preeminent in nursing. Red
Cross nurses were trained in a two-year hospital course
following the German and the Scandinavian Red Cross pat- 16 terns. Until then, nursing services which had to do with
cleanliness and the comfort of the patient were carried by 5 9 • 755 • • 19 7 servants. ' ' ' The Russian word for a nurse is sestra
(sister) . It was first used by the Red Cross nurses who
belonged at the beginning to a submedical rather than a
nursing class, for they were employed chiefly for dres- '^^^''^•^^^'^^•^'^^ sings and treatments.^' As early as the
1870s, women started studying medicine and stood high in
the profession, for in Russia, intellectual equality for
142 143
men and women was recognized and professional study by women 6:240 was greatly^1 encouraged.A
The Russian Revolution
The revolution of 1917 and the radical changes that
followed wiped out most of the old order and under the new
Communist government an entirely new system of medical and health care was established. The class structure was changed with workers given first appointments in educational fields
and work. A system of secular ethics was introduced which
called for complete subordination of the individual to the 20:345-6 authority^1, of^ the State.c*- .
A unique feature of the Soviet system was the
adoption of a nationwide health scheme based on the health
needs and resources of the country. This resulted in a five-
year plan which was subsequently divided into quotas for
every field, with the military services having first prece-
dence then. . Many women were assigned to medical and health
services and many educated men who belonged to the upper
2 0 * 3 A- 7 class were drafted as officers and engineers in the army.
Medical practice was reorganized into lower, middle,
and higher levels. This set up a three-step vocational
ladder that separated the unskilled from the skilled, and
the skilled and semiprofessionals from the professionals. '
No strict lines were drawn between the different levels
designed to allow for mobility of workers from one rung ^: 144
to another, provided they qualified by additional prepara-
tion and experience. The government also sensed a shortage
of nurses and the great need for their services. This
resulted in the establishment of many schools of nursing
that offered short courses in an attempt to train nurses.
Later, many f ledshers , both men and women, received a three-
year training course that prepared them to become doctors'
assistants. This group of nurses was allowed to do minor 8 51-2~ surgery and prescribe medicine. '
Nurses along with the fledshers and midwives
belonged to the middle medical category. On the lowest
level were the aides and orderlies who had some practical
training after the four years of general education. Phy-
/ 0 0 1 sicians belonged to the highest level. ' Many women
physicians in Russia had taken nursing or midwifery train-
ing before they went into medicine. This makes the nursing
profession in the Soviet Union a half-way house among other
career levels and explains the lack of leaders in the nursing
^^^"^ • -^^^ field at the time. ' ^ In other words, nurses' preparation was considered a step toward qualifying as a physician.
Since all the health work was done by the government in Russia, which was, in a sense, in the field of public health, little distinction existed between the public health nurse and the institutional nurse. No private hospitals, private nurses, and private journals existed in Russia 145
besides those that are government ovmed. The nurses were
trained, employed, and paid by the State. The whole health
system was controlled by the Narkomzdrav or the Ministry
of Public Health, which governed and determined nurses'
training and practice. In 1935, the first law defining the
title nurse was passed. It stipulated that only graduate nurses of a recognized hospital training school of nursing who passed the final examination could be considered
2 • 525 nurses. Through the enactment of this law, nursing became a profession with the defined duties and responsibil-
ities. Nursing education witnessed the integration of theory and practice and the setting of admission requirements for all
o r o ti C candidates applying to enter the nursing schools.
All nursing programs started with a two-year program, at ''"^ the end of which a certificate was issued. ' Specialty areas in midwifery, public health, and pediatric nursing were available in a one-year course for graduate nurses who
' achieved outstanding results in the final examination .
The two-year graduate in Russia always worked as an assistant to the physician, '"^ '^^^ whereas the three-year graduate had more medical responsibilities and functioned on the same
''"'^ ' level as an intern in the United States . '^^ The fledsher functioned only occasionally as a nurse in the hospital.
Most frequently this group took responsibility in directing a collective or state farm district clinic, a rural health center, or a first aid medical station in a mine or 146
a factory, and in some places acting as a substitute for
• • 7:883 the physician.u
Nurs ing . Organization
With the establishment of the Communist regimes,
all workers were required to join one large union which
includes all levels of health personnel, Soviet unions
differ from other unions in the western world in the fact
that they are not self-governing since they are a part of
the State machinery and subject to control by higher
authorities. As a result, these unions are not allowed to
bargain for better conditions and salaries, or to resort
to strike if negotiations fail. Their chief function is
to stimulate production in industry and to work for the
improvement of health care administration. Many types of
discipline are employed by unions for offenses or incompe-
tent work. Also, a system of honors was developed for good
work and accepted communist conduct. Attendance
at union meetings is compulsory, for all USSR citizens are
supposed to do some voluntary social work through the unions
as a contribution to the welfare of the general public.
All nurses are encouraged to participate in the
local community and governmental organizations such as the
Red Cross, Local Soviets, or other voluntary and governmen-
tal bodies. Professionally, besides membership in the medical workers union, nurses have attempted to organize 147
themselves in a society for the pursuit of professional
interests. The Moscow Bothin Hospital has had a Nursing
Soviet Council since 1938. In 1958, the Ministry of Health
described procedures for organizing similar councils on
local hospital levels. This body of nurses was responsible
for conducting programs in nursing as well as seminars on
issues and problems facing the profession. Some councils
acted as inspection groups that examined and evaluated the
•7 . Q Q O work of lower medical personnel. '
Nursing Education
At present in the USSR a young man or woman can
enroll for training in a nursing school upon the completion
of eighth grade. The training requires three years; a high
percentage of the time is given to general education, and
courses such as history, social science, literature, physics,
chemistry, and a foreign language are offered. Upon comple-
tion of the program students receive a general education
certificate plus a tenth grade certificate which allow them '^^^ to apply for university education. However,
students who have already finished ten years of secondary
school skip the above-mentioned subjects and go directly to
the medical subjects, which include medical Latin, biology,
anatomy and physiology, microbiology, pharmacy, hygiene, and health systems and administration. Special nursing subjects include care of internal and surgical diseases, anatomical 148
and physiological peculiarities of children, care of children
under one year of age, communicable diseases, nervous and
psychiatric diseases, dermatological and venereal diseases,
eye, otolaryngological diseases, physiotherapy, physical
1 209 7' culture, and pathology. •
No teaching is done by nurses. Basic courses are
taught by the faculty from the respective social sciences
departments. Physicians are responsible for the teaching
of clinical subjects and for the training of nurses, which 1 • 2098 is carried in Oblast hospitals. " During the first
year students' hospital experience emphasizes care of the
environment. Patient care starts in the second year during
which students are taught to give injections and handle
technical equipment. Throughout this period technical compe-
tency is emphasized. The third year provides students with
an extensive practice period during which they rotate on
different wards and get ready for the State examination.
The head physician's recommendations of the students serve
as a requirement for admission to the examination. At times
the physician recommends additional study for the student to take before graduation.
Training and distribution of meditim- level medical personnel are planned in accordance with the overall plan
of development of the health service and extension of the network of medical colleges. Instruction in the Soviet
Union is free, and hence the right to enter these colleges 149
is enjoyed by all citizens under the age of 30, Entrance
examinations must be passed before admission to the medical
colleges. Upon graduation from the college, employment is
provided to all in accordance with the distribution plan of
12 • 25 7 the local health services. ' As a general rule, all
students who enter nursing schools in Russia are attracted
to medicine. More than 20 percent of the graduate nurses,
after a few years of experience, apply to medical schools 17 21 11 • • • 528 to become physicians. ' ' ' Nurses and doctors are
obliged to take refresher courses of one to six months
depending on the area of specialty. Students in these
courses are entitled to an allowance and living accommoda-
tions in addition to the salaries. Annual leaves with pay
are also available to nurses interested in working in dif-
1 C O ^•->^°~^. O Q Q ferent areas as a measure of updating their knowledge.
The training of a fledsher is similar to that of
a nurse, but requires six additional months for specialty
training. Students in this group receive special prepara-
tion in first aid, diagnosis, and relatively independent practice under a physician's supervision. A graduate
fledsher usually functions as an independent practitioner
in a fledsher station. The midwifery training program is
much the same as the f ledshers ' program but with emphasis on obstetrics rather than surgery. Practice is partly in general hospitals, but mostly in maternity hospitals ^^^^ 150
Advanced nursing education as head nurses and
anesthesiologists or as special surgical nurses is de-
cided by the head physician who establishes whether a nurse
is eligible for it. Two-year courses are offered at the
Medical Education Institute in Moscow to nurses sponsored
by the hospital administration. Further education for
nurses covers areas such as physical therapy, surgery,
obstetrics, pediatrics, psychiatry, and neurology. The
number of nurses admitted to these programs depends on the 1 '• 2099 kind of specialty training that the system requires.
Nursing Service
The present Russian medical plan emphasizes train-
ing of medical sestras — nurses — in a program that has
advanced training in preventive care. The new medical
practitioner and the medical sestra are then assigned as
a team to work in a rural s tation ."'"'^ The sestras at the
present are functioning in hospitals, polyclinics, and
ambulatory health services and in this role serve as assis- •''^^^^'^^'^'^"^ tants to the physician.
The fchief physician in every Russian hospital is
also the chief administrative officer. The chief nurse is
directly responsible to the chief physician and essentially
acts as his assistant. Senior nurses in different depart- ments are automatically responsible to the senior physicians of the respective departments and work under their direct .
supervision. Senior physician and nurse work as a team
to supervise the services provided in a unit. No nursing
service department is available and hence no direct line
of authority exists between staff nurses and the chief
15:28-9 . • nurse. Russian^ . nurses apparently^1 do not^ believeu T m
a nursing hierarchy, but instead, the doctor, the nurse,
and auxiliary personnel work as a team with the physician
in charge. This pattern also prevails in polyclinics and
other health units where duties are perceived as inter-
15 • 29- 30 changeable. " It is of interest to note that the nursing profession is not reserved exclusively for women
in Russia. Many male students join the nursing schools;
21 • 5 29 - 30 however, most of them become f ledshers
Health Services
In the Soviet Union the provision of health care
is guaranteed by the State. No direct charges are made to
the patient. All health services are unified, centrally
directed, and accessible to all persons in need. The system is characterized by a degree of centralization of planning and direction at the national level and by decentralization of execution and implementation at the four lower levels. These are the Republics that are fifteen in number, the Oblast which is a province of the
Republic, the Rayon which is a subdivision of the Oblast, ^^^^ and the " Uchstok or the local dis trict . Each of the 152
Republics has a Ministry of Health, each of the oblast
and rayon has a health department which controls the ucha.tok.l'2099;3:1592 .
The hospital system in USSR includes the uchastok hospital, the rayon hospital, and the oblast or city hos- pital. The punkt or station is the smallest unit and is
run by fledshers or midwives . It serves as the first contact point of the patient with the health care delivery system. Patients admitted to the uchastok hospital who need a specialist's attention are referred to either the rayon
. ^ ; : 85-6 or the oblast hospital ^ ^099 19
The polyclinics are the heart of the Soviet health care system, with prevention as their primary goal. All polyclinics have their own staff of medical specialists in addition to providing the public with various paramedical services. Physicians who serve in uchastok hospitals also have offices in the polyclinics. Vaccination, immunization, and followup care are provided by sanitary epidemiological centers which are separate from the polyclinics. The USSR places considerable reliance on these centers for improving and maintaining the health of the Soviet people. Some of these polyclinics are integrated with rayon or oblast hos- pitals, whereas others are independent and frees tanding
The nursing profession enjoys prestige in the USSR; many nurses are elected to political offices. This is attributed to the heroic work done by nurses during 153
World War II as well as to the competent and devoted work presently done at the various levels. The chief difficulty with the Russian system, however, is that it does not provide any real identification for nursing as a profes- sion as separate from other fields. Instead, one finds nursing acting as a halfway point on the professional ladder. . .
"'•'5^;c
154
References
1 Abdellah, F. Nursing and health care in the USSR. American Journal of Nursing, 1973j 2096-9.
2 Albin, E. Nursing in the USSR. Ame^.'ioan Journal of Nursing, 46, 525-8.
3 Armstrong, J. Health services in the USSR. Nursing Times, 1965, 61, 1592.
4 Bullough, V. and Bullough, B. The emergence of modern nursing (2nd ed.). London: The Macmillan Co., 1969.
5 Dock, L. Hospital nursing in Russia. American Journal of Nursing, 1909, 9, 155-1
6 Dock, L. and Stewart, I. A short history of nursing New York: G.P. Putnam's Sons, 1938.
7 Ensberger, M. Nursing in Russia. Nursing Outlook, 1963, 11, 883.
8 Goodnow, M. Nursing history (9th ed.). Philadelphia: W.B. Saunders, 1955.
9 Hoffman, I. Progress in Russia. American Journal of Nursing, 1913, 14, 197-8.
10 Holliday, J. Glimpses of nursing in Russia. Nursing Outlook, 1958, 6, 496-7.
11 Ikonnikova, J. Nurses in the Soviet Union. Inter- national Nursing Review, 1963, 10, 11.
12 Kolylima, G. Nursing in USSR. International Journal of Nursing Studies, 1957, 4, 257.
13 Leitz, D. Nursing in the Soviet Union. Nursing Mirror, 1964, 117, 64-6.
14 Morris, K.H. Profile of a Russian nurse. American Journal of Nursing, 1966, 66, 549-51.
15 Mussallem, K.H. A glimpse of nursing in the USSR. Canadian Nurse, 1967, 6Z, 27-33.
16 Noyes C. , Establishment of foreign training school. American Journal of Nursing, 1919, 19, 2U1-8. 155
17 Powell, A. Journey to Moscow. Nursing Times, 1964^ 60, 481
18 Powell, A. Nurse training in USSR. Nursing Times,
. 1966, 62, 1600-1.
19 Quinn, S.E. Nursing in the Soviet Union. International Nursing Review, 1968, 15, 75-86.
20 Stewart, I. and Austin, A. A history of nursing. New York: G.P. Putnam's Sons, 1962.
21 Tarassova, G. An honored profession. Nursing Times, 1973, 69, 527-30. PART IV
AMERICA CHAPTER 11
CANADA
The development of nursing in Canada was influenced
first by the religious orders who came from France to
establish hospitals and homes for the sick, second by the
Nightingale system and the Victorian Order of nurses, and
third by the United States which has been responsible for
the more recent developments. Modern Canadian nursing seems
to be greatly influenced by the developments in American
nursing. On the other hand, Canada has furnished the United
States with some of the outstanding leaders of the profes- 3.^^_7:447;17:122
The first Nightingale Schools of Nursing were started
at about the same time in the United States and Canada.
Dr. Theophilus Mack of the General and Marine Hospital in
Ontario introduced the Nightingale nursing system to Canada
in 1864 and later sent a Miss Money to London to study at
St. Thomas's School in 1873. On her return a school of nursing was established and soon other hospital schools developed in larger cities. The Toronto General Hospital was the first to open in 1881 under Mary Agnes Snively, who had graduated from the Bellevue Hospital in New York.
157 .
158
In 1890, the Montreal General Hospital School of Nursing was
started under the leadership of Norah Livingston who was also
a graduate of the New York Hospital. The history of Mary
Agnes Snively and Norah Livingston mainly constitutes the
^^"'""^ ' history of " = nursing in Canada . ^ Graduates
from both schools functioned in every part of Canada, build-
ing, developing, and reforming nursing schools.
The first school of nursing in the French Catholic
Hospitals was at Notre Dame Hospital in Quebec which was
founded in 1899. Hotel Dieu School of Nursing was then
established at Montreal in 1901, and in 1920 was affiliated 19:239-40 with the University of Montreal. ^^^^ Victorian
Order of Nurses, a public health nursing service, was founded in 1897 by Lady Aberdeen. Its work involved all people in
all districts and was expanded through the Lady Grey Country
District Nursing Service in 1909 to cover country districts
7 : 451- ; 2 19 : 199- 200 ^ . . in oanaaa.Canada Training covered, different, fields of study, preparing graduates to function as midwives,
school •'"^^^ 1^ ' '^^^ nurses, and tuberculosis officers '
The Canadian Red Cross
The organization of the Canadian Red Cross was founded in 1896 by Dr. George Sterling Ryerson. Prior to the First World War, the Red Cross Societies confined their activities to war services, but during the war, efforts were turned toward the prevention of communicable diseases. This resulted in the first mandate in Canada which provided 159
facilities for the postgraduate training of nurses in public health. For many years the Red Cross financed the employment in rural districts of public health nurses whose main work dealt with the prevention of disease and the
' ^ education of the public. ''"^^
In other respects the development of Canadian nursing has closely followed that of nursing in the United States.
This was most obvious in the early affiliation with the university. In 1919, the first department of nursing at the University level was established as a result of the cooperation of the University of British Columbia and
Vancouver General Hospital. Other schools were soon estab- lished in other universities, such as McGill, University of
Toronto, Notre Dame, and University of Manitoba and Alberta which offered the bachelor's degree in nursing. The Cana- dian nurses were organized along similar lines to the
American nurses. The original Associated Alumni and the
Superintendents' Societies encompassed both Canadian and
United States nurses. This union split in 1907 and the
Canadian National Association of Trained Nurses was
: 453-4; : formed. ^ 19 267
Nursing Organizations
As noted earlier, nurses of Canada had joined with those of the United States to form the American Society of
Superintendents of Training Schools for Nurses, founded in 160
1893 and followed in 1896 by the establishment of the Nurses
Associated Alumni of the United States and Canada. Nurses
from the Associations were active in launching the first
graduate program in nursing at Teacher's College, Columbia
22 ' 2 A- A- University, which opened in 1899. " Incidentally, the
first two nurses to take a leading role in establishing the
program, Isabel Hampton and Adelaide Nutting, were Canadian
by nationality.
As a result of the organization of the International
Council of Nurses in 1899, Snively, acting as the organiza-
tions' first treasurer, began a movement which led to the
splitting of the United States-Canada associations and the
formation of the Canadian Association of Nursing Eucation.
This was done to achieve membership in the International
Council of Nurses which was then organized on a provisional
basis allowing only national nurses associations to become
22 2 A A- 5 members. ' In 1909 the Canadian Nurses Association became the fourth member of the International Council of
Nurses, and in 1922 nursing lav/s V7ere secured in all the provinces. In 1924 the Associated Alumni and the Associa-
tion of Nursing Education merged, resulting in what is now known as the Canadian Nurses' Association. The newly formed
association had three sections: nursing education, private
duty nursing, and public health nursing. In 1930 a feder- ation of provincial associations was formed, each securing
' ^'^^ complete ^ ' autonomy in dealing with its own problems . 161
Similar to the American Nurses Association, the
Canadian Nurses' Association owned and controlled the
Canadian Nurse, a journal established in 1910.
Speial mention should be made of Jean Wilson and Ethel
Jones who were instrumental in moving the journal from an alumni quarterly to a national and then international
• 4-- 7:454:22:245 • publication.ui The Canad^an^ J- Nurse„ continued^ J to^ develop and now publishes English and French editions
that are widely distributed and respected throughout the world.
Nursing Education
The majority of nursing schools were operated by hospitals that provided for students free room, board, tuition, and, in some instance, a small monthly allowance, in return for a substantial amount of service. That arrange- ment created a conflict and weakened the educational expe-
1 • 35 rience of students. ' However, by the end of the First
World War, Canadian universities opened their doors to nurses and McGill and Toronto started offering a one-year course for graduate nurses. McGill University was under the leadership of Flora Madelaine Shaw and Toronto Uni- versity •'"^ ' under Kathleen Russel . -"-^^ As was mentioned earlier, the first Canadian five-year program leading to a university degree was offered under the joint auspices of the University of British Columbia and the Vancouver 162
Hospital School of Nursing. The program was directed by
Ethel Johns. These university programs were preceded by a centralized curriculum established to reduce duplication of courses in different schools of nursing. The Canadian
Nurses Association started this movement which was later transferred to the different universities where lectures were given by the medical staff. Not long after that the
Association's efforts to bring nursing to the university 6:52 level1 1 boreK fruit.^
As in most other countries, Canada had trained, partially trained, and untrained women who engaged in practical nursing. In 1920, hospitals introduced an auxiliary staff of aids who were placed on the wards to work under the direction of nurses. These were known as nurses' aides. Their responsibilities were to assist nurses in carrying on simple duties associated with patient care.
Later, another kind of auxiliary worker was introduced to the nursing scene, the certified assistant nurse. The student in this group was prepared under the direction of nurse insructors in schools financed by the government in 3-27 a one-year training program. ' The new emphasis on team nursing contributed to the development of the different levels of nurse preparation, placed nurses in leadership positions, and gave them more responsibilities in coordi- nating nursing service. 163
The essential responsibilities of professional
nurses changed as a result to include the giving of skilled
nursing care; health teaching and counseling; making accurate
observations and communicating them to others; selecting,
training and guiding auxiliary personnel; and planning health
3 • 2 8 services to meet community needs. ' These demands on
nurses required a sound and scientific nurse- training to meet
the challenges that the expansion of science is imposing
on the profession.
Besides the two technical programs that exist for
the training of nurse-assistants, two other levels of
nursing education existed in Canada. The preparation of
one level of practice was carried at the university level
and the other in a diploma program at the post-high school
level. The university program provided a sound foundation
of theory and practice with an academic preparation for
leadership positions in nursing. ''"^ ' ^^"^ Postbasic education
was also available to nurses in different areas and was
offered in the universities. In 1942, the University of
Toronto established the first integrated basic baccalaureate program, and the University of Western Ontario in 1959 was
the first to offer a course leading to a master's degree
in nursing. 1^=1627;15:30;18:31
In 1965, basic baccalaureate programs in Canada fell into two classifications; integrated and nonintegrated. 164
The integrated program leading to a baccalaureate was con-
ducted as an integral part of the university, whereas the
nonintegrated nursing program was divided between the
university that offered the science courses and the diploma
school of nursing that provided the nursing portion of the 18 32 program. ' However, this trend disintegrated in 1970
when all universities offering the nonintegrated program
started to offer the integrated one.
Nursing Studies
The first major study of nursing in Canada was
a joint effort of the Canadian Nurses' Association and the
Canadian Medical Association. It was completed in 1932 by
Dr. George Weir. The study which focused on nursing and nursing education at the time concluded that changes
should be made in the system of nursing education and
recommended removal of nursing schools from hospital 16:36 control.^ T
An experimental program in nursing education was started in 1948 under the sponsorship of the Canadian
Nurses' Association, the Canadian Red Cross, and the
Department of National Health and Welfare. The evaluation of the project, carried over a five-year period, showed that a clinical nurse could be trained in two years. As a result, many schools of nursing reorganized their programs to include a two-year basic training period followed by a final .
165
year of internship. This became known as the "2 + 1" 16:37-8 pattern.
A 1950 study provided valuable data on the supply of nurses. It was conducted by the Committee on Public by Health Practice headed by Dr . J. H. Baillie and a nurse
the name of Lyle Creelman, internationally known for her
extensive work with the World Health Organization. The
study showed a wide range of nursing practices in the city
and rural districts which did not meet the health needs of
the person. This led to an increase in the number of schools
offering public health programs as v/ell as to the establish- ment of a university-level postbasic degree in public 12 health.
Studies, experiments, and plans are widespread in
present day nursing profession and their popularity is
constantly on the increase. Some of them have contrib-
uted to the solution of many problems in nursing while the
•fruits of others are still unknown. However, the fact is
that these studies have aroused public interest in nursing
leading to a greater sense of responsibility on the part of
the government, the people, and many members of the nursing
and the medical professions
Present Trends in Nursing Education
In 1965 the two-year diploma program of correlated
theory and practice followed by a year of internship gave way to the new two-year program. Independence from hospital 166
control was also achieved through creation of a school management committee as the governing body for the school.
Before that diploma schools of nursing were under the direct administration of the hospital nursing departments. The responsibility of the school administration is now vested in one person whose main interest and job is nursing educa- tion. This change has facilitated a shift from apprentice teaching to a learner- centered program where students util-
• 13:555;21:40 ize hospital1 areas to fulfill^ 1^-11 educational^ ^- ^ objectives.u-
Today, the student in a Canadian diploma program is taught nursing principles and their application to specific nursing situations. Nursing content is focused on health and the factors related to the levels of wellness and the preparation of the student to meet the health needs of indi- viduals families, and the community. Courses are presented , in broad areas related to fundamentals of nursing care, nursing in physical and mental illnesses, and maternal and child care. Pharmacology, history of nursing, ethics, legal aspects, rehabilitation, and various therapies are integrated in the major nursing areas rather than presented as separate subjects. The new curriculum stresses both prevention and cure and hence utilizes community as well as hospital facil- 21:41 ities. Several revisions have also been introduced to the basic university course. At present the curriculum provides a basic professional preparation that includes qualification ^
167
for the practice of nursing in the hospital and in public health fields. It also qualifies nurses for teaching,
administrative, and research positions. In the four- year program nursing theory and practice are integrated
and associated with studies in the humanities and the
sciences. Graduates are expected to show a capacity for
leadership in assessing, planning, providing, and evaluat-
ing nursing care. They are also provided with an educa-
tional base for further study as practitioners, teachers, 2:46-8 administrators,... consultants,1. . and^ researchers.u
Twenty-two universities in Canada offer basic courses
leading to the Bachelor of Science degree. The nonintegrated
courses, referred to earlier, have been phased out. Many
of these universities also offer baccalaureate degree courses
to registered nurses interested in adding to and deepening
their knowledge in nursing. Another development in nursing
education at the university level is the introduction of
postgraduate courses in nursing at the master's level to
prepare nurses for leadership and research positions . ^ '
The Expanded Role of the Nurse
A joint committee of the Canadian Nurses' Association
and the Canadian Medical Association met in 1972 to discuss
the expanded role of the nurse. A general agreement existed
among the participants that the improvement and effectiveness of Canadian health services could be better achieved by 168
expanding the role of the nurse than by creating a new
category of health workers. As a result, the nurse practi-
tioner's role was created. It expands into many areas such
as obstetrics, pediatrics, orthopedics, family care, and
primary health care.
This educational program for nurse practitioners
originated at the University of Toronto in response to a need
for additional preparation of nurses to serve the Northern
Canadian population. Following that, short courses were
developed in six Canadian universities to assist nurses to move into ^ ^^"'"^ practice in primary care settings . '
McMaster University in Hamilton, Ontario, has two under-
graduate programs in the health field, one in medicine and
the other in nursing. Both programs give high priority to
the preparation of primary care physicians and nurses.
This program was the result of an effort by educators and
practitioners in nursing and medicine with social workers making major contributions to the planning and operation of 9 20 21 such services. " " This program is presently offered to graduate nurses with state registration.
Teaching in the nurse-practitioner program is shared by the faculties of medicine and nursing. Educational objectives cover four broad areas: assessing health needs, including history taking and physical examination; planning, which emphasizes a problem-solving approach; management of common illnesses and deviation^ from normal, and evaluation 169
of the health care provided. Deviations from the pattern
are cominon and intended to meet the diversity of student
^"^ ^ needs . ' The work done by these graduates has been praised by physicians and other health workers who
support the new expanded role of the nurse and who believe
that nurses can be trained to practice the delivery of primary health care and hence relieve the physician for the more complicated and specialized aspects of treatment. 170
References
1 Carpenter, H. Canadian conference on nursing. Canadian Journal of Public Health, 1958, 49, 34-7
2 Carpenter, H. The Canadian scene. International Nursing Review, 197^, 21(2), 43-8.
3 Carpenter, H. The role of the nurse in the total health program. International Nursing Review, 1951, 4, 24-30,
4 Expanded role of the nurse. Canadian Nurse, 1973, 69, 23-5.
5 Gibbon, J.M. and Mathewson, M. S . Three centuries of Canadian nursing. Toronto: The Macmillan Co., 1947.
6 Gunn, J. Centralization of teaching in schools for nurses. Modern Hospital, 1921_, 16, 51-3.
7 Jensen, D.M. History and trends of professional nursing^. St. Louis: C.V. Mosby, 1955.
8 Jones, P.E. Symposium on community nursing in Canada. Nursing Clinics of North America, 1915, 10, 691-8.
9 Kergin, D.J. A Canadian educational practice in family practice nursing. International Nursing Review, 1915, 22, 19-22.
10 Loyer, M.A. Should nursing education be under the domain of hospital. Canadian Nurse, 1966, 62, 25-6.
11 McCloud, C. District nursing in Canada. American Journal of Nursing, 1901-2, ii, 503.
12 McLure, R.E. Education of public health nursing personnel. Canadian Journal of Public Health, 1966, 37, 260-2.
13 Morgan, M.P. Planning for curriculum changes. American Journal of Nurses, 1968, 68, 554-6.
14 Mussallem, H.K. Nursing in Canada. Nursing Times, 1966, 62, 1626-9.
15 Mussallem, K.H, Nursing in Canada from pioneering history to a modern federation. International Nursing Review, 1968, IS, 29-34. .
171
16 Mussallem, K..H.. Studies on nursing in Canada. Inter- national Nursing Review, 1967j 14, 35-42.
17 Nutting, M.A. and Dock, L.L. A history of nursing (vol. 3). New York: G.P. Putnam's Sons, 1910.
18 Rowsell, G.S. University nursing education. . . .Facts and trends. Canadian Nurse, 1966^ 62, 31-3.
ed ) 19 Sellew, G. and Ebel, E. A history of nursing (3rd . St. Louis: C.V. Mosby, 1955.
20 Seymer, L. A general history of nursing . London:
Faber and Faber . Limited, 1935.
21 Steed, M.E. Trends in diploma nursing education. Canadian Nurse, 1968j 64, 40-1.
22 Stewart, I. and Austin, A. A history of nursing. New York: G.P, Putnam's Sons, 1962.
23 Wood, T. The practice of medicine by nurses: An opinion. Canadian Medical Association Journal, 1916, 114, 947. .
CHAPTER 12
THE UNITED STATES OF AMERICA
Although nursing is as old as the human race, productive efforts to achieve professional status in the
United States dates back little more than a century to the beginning of an organized system of nursing in 1870.
The pioneering work done by women during the Civil War contributed to the establishment of trained nursing in the country. These women had no training as nurses but had a high degree of skill which they acquired through 9:132-3 practice
In 1873, the first American schools that adopted the Nightingale system were established at Bellevue
Hospital in New York City, at the New Haven Hospital in
Connecticut, and at Massachusetts General, Boston;^ The
Women's Hospital in Philadelphia and the New England
Hospital for Women and Children had striven for years to 22" 388-9 train nurses. ' In 1361, the Women's Hospital in
Philadelphia opened a school organized and conducted by two women physicians. This attempt was not fruitful and the school was reorganized in 1872 to be endowed by a 20-2 73 Dr. Dodd. ' Also, the New England Hospital for Women
172 173
and Children under the direction of Marie Zakrzewsky, began
teaching nurses as early as 1860. Training of nurses in
that school was rudimentary until Suzan Dimock took over in
1872 and reorganized the school under the Kaiserwerth '^ system. ^ Linda Richards was the first trained nurse
to graduate from this school and later through personal
contact with Miss Nightingale, organized the New England
Hospital School, with a nurse instead of a physician as
"'"^ • -"-^^ '-^ -^"^ • = head of the nursing gtaf f .
After the pioneer period, schools were founded at
a rapid rate in many hospitals throughout the country.
The Red Cross Hospital, started in New York before 1900 by
Clara Barton, trained nurses for service during war and
natural disasters. The course took two years and three months and the title Red Cross Sister was given to graduates The school failed gradually as many of the demands for
training nurses were fulfilled by the new modern training schools that were developing then in connection with the ^3:90-l;23:194 hospitals. Up to this point the nursing school was a part of the hospital and was accordingly admin- ^^^"1 istered by a number of ^ = the medical staf f . Hospitals saw the schools as an economic advantage that provided better nursing care for their patients. Few, however, recog- nized the importance of the schools in providing skilled nurses for their community .-'"^ 174
Nursing Organizations
The earliest American nurses' association was the
Philomena Society which was formed in New York in 1886.
In the early 1890s, small local groups and alumni associa-
tions began to be organized and later joined together to
. ''"^ "'"'"^ form the basis for a national association " The first
steps were taken by the graduates of the Bellevue Hospital
School of Nursing in 1899. They formed an alumni associa-
tion whose chief purpose was to foster fellowship, mutual
support, and school loyalty, and to provide economic assis- 23 • 199 tance in case of need. ' Isabel Hampton was the first nurse to push the idea of a national nurses association, as early as 1890.
In 1893, at the World's Fair in Chicago, a group of nursing leaders met to consider the development of national standards and administrative practices of schools of nursing.
During the same meeting the group explored the possibilities of organizing a national nursing society. As a result of these talks, the American Society of Superintendents of
Training Schools of the United States was established.
The Nurses Associated Alumni of the United States and Canada, with Isabel Hampton as president, came to existence at the same meeting and concerned itself mainly with memberships.
This same organization was named in 1911 the American Nurses
Association. This historic meeting was the genesis of organized nursing in America. ^ ' 175
The purpose of the American Nurses Association was
to establish and maintain a code of ethics, to elevate the
standards of nursing education and practice, and to pro-
mote the usefulness and honor, the financial and other
interests '''^ '""'"^ of nurses and the nursing profession. '
The Society of Superintendents continued to devote its
efforts to educational advancement and in 1912 changed its
name to the National League of Nursing Education. This
organization, by providing educational opportunities for
students at the school and university levels, was a leading
force for educational progress in nursing in the United
Qt-nf-oo 10:165-6 , ^. ^ i>caces. A third organization came into being in
1912 as an expression of the growing importance of the
visiting nursing or public health service. This was known
as the National Organization for Public Health Nursing.
"""^ '^^ '-^''"^ Lillian • ' Wald was its first president. •
Sophia Palmer, one of the leading members of the
National League of Nursing Education Organization urged
New York State to pass a law that would require supervi- sion of all of its nursing schools by the university of the
State of New York, and the licensing of all graduate nurses after they passed a theoretical and practical examination. The same year Mary Davis, one of Sophia Palmer's friends, launched the first issue of the American Journal of Nursing under Sophia Palmer's editorship. The registration of nurses and the fight for State legislation were the main 3
176
12 23 201-2 • • 252 ' issues launched by the journal. ' This impetus led to establishment of nurse registration laws in North
Carolina, New Jersey, New York, and Virginia in 1903 and in the rest of the States by 1923. State registration acts brought with them definite improvements and uniformity in nursing school programs which led many schools to adopt the three-year training program that later became the standard
. . 1 11:255-6;15:281 for nursing education.^.
The National League of Nursing Education Committee, with Adelaide Nutting as chairman, prepared and issued a book in 1917 on the standards of a school of nursing curri- culum. They included teaching as well as administrative recommendations. Also, in 1912, the National Organization of Public Health Nursing organized voluntary and official agencies for home and community nursing services. It also supervised and evaluated postgraduate courses in public health nursing. All national associations had had many purposes and interests in common and although they carried different functions, they worked together closely for the
23 • 202- improvement of nursing at all levels.
Nursing Education
The advance of preventive medicine and public hygiene and the broadening of the nurses' field, emphasized the need for a broader and sounder education than the hospital schools of the day offered. In addition the Spanish-American War brought dissatisfaction with the haphazard trend of nursing 177
education at the time. All these factors provided an
opportunity for the American Nurses' Association to
demonstrate the usefulness of the organization to the
'"^ public . ^ The solution to the problem depended on
the establishment of graduate education for those nurses who were in charge of education of nursing students in the
various schools of nursing. As a result, a committee with
Isabel Hampton Robb as chairman, and Adelaide Nutting as
a member, organized a course with the help of a Dr. Russel
at Teachers College, Columbia University, New York. Regular
courses in psychology, science, and household economics were offered to selected graduate students at the university, while special courses in nursing were provided at the school
"''^ ' of nursing itself . Gradually, this course expanded
and in 1907, Nutting became the first professor of nursing
at the university. A new department in administration was
then established. It included the division of hospital
economics. This department, under Nutting's guidance,
gained international fame and attracted nurses from many 13:130-1 parts of the world.u
Connections with the university world had a profound influence on the profession. Many liberal-minded educators became interested in problems of nursing schools and as a result gave invaluable advice and support to the develop- ment of the profession. The movement brought many changes among nurses themselves, who saw the need for a better 178
balance between theory and practice, the science and art of
nursing, and the processes of education and training. This
resulted in nurses setting their own aims and policies,
defining their roles, and studying their problems more
objectively in the light of fundamental principles and the
wide experience of experts who were available to them in the
"7 o o . o r\ c various fields of education.
At the basic education level, a preparatory course
was developed by Nutting at the Johns Hopkins Hospital in
^ ' "'"^'^ 1901 but it received little support . However, in 1909
a full course in nursing was established at the University
of Minnesota by Dr. Richard Beard, under the direction of
Louise Powell. This course was the pioneer in basic nurs-
"'•''^"^ ^'^''"^ "^^ " ' ' ing education at the university level .
The University of Cincinnati and Teachers College offered
courses in nursing education in 1916 in a program that led
to a degree. In 1923 the first independent university
school was established at Yale with its own dean and a sub-
stantial "'"'^ '"''^ endowment by Ann Goodrich . ' Students in this
program completed two years of college work before entering
the hospital for an additional 28 months of experience at
the end of which a bachelor's degree in nursing was ^-^^^ granted. Soon nursing, like many other professions,
found a permanent place in many American universities that were flexible in combining academic and professional studies. 179
Two aspects of nursing education were the gradual improvement in entrance requirements and the introduction of a preliminary course preceding the graduate course.
Besides, special training was required of the nurse who was to do visiting nursing, resulting in the development of a postgraduate course in public health nursing at Teachers
College. Later, public health nursing became an integral part of all higher education curricula in all the profes-
, . . 13:131;23:208 sionalT schoolsT of nursing. '
To help meet long-term demand for military nurses, the army school of nursing was organized in 1918 during the
First World War, with Annie Goodrich as dean. A three-year course with a special nine months credit to college grad-
15 * 262 uates constituted the curriculum. ' The American Red
Cross and Vassar College also offered a three months pre- liminary course to college graduates, some of whom were nursing graduates. In civilian hospitals and homes, the war created a real shortage of nurses. This resulted in the development of a health education course that was offered to housewives and conducted by well-trained nurses.
Although this plan, organized by Jane Delano, was opposed by many nurse educators of the day, the American Red Cross has continued to offer these courses as an important
- o peacetime activity. * ; • Another consequence of the war was the development of nursing military status, achieved through the diligent efforts of many nurses who 180
served during the war. Julia Stimson, then Superintendent
of the Army Nurse Corps, received the rank of major and
other army nurses' corresponding ranks went down to second
lieutenant.
The war also highlighted the need for more develop-
ments in medical and health related fields. As a result,
several studies were initiated by nurses and supported by
the Rockefeller Foundation and other agencies. The result
of some of these studies strengthened the position of
nurses and called for a combination of health teaching with
nursing service. An immediate outcome of the study was
the establishment of an experimental demonstration school
at Yale University, endowed by the Rockefeller Foundation,
and a similar one at VJestern Preserve University, endowed by ^"'"^"^ Francis Bolton. '
Nursing Studies
Based on the Flexner study, which graded medical
schools in the USA and Canada, the Committee on the Grading of Nursing Schools was formed, with representatives from medical, nursing, and hospital organizations. The purpose of this committee was to help in raising the standards of nursing schools by means of a classification system to make it possible to give recognition to those schools of good standing and to stimulate others to improve their stan-
, , 10:180-l;23:215-6 "'^^^^ , • A five-year program was adopted in 1926 to cover projects such as the supply and demand for 181
nursing service, job analysis of nursing and nurse teaching, and actual grading of nursing schools. The practical results of this study were the elimination of inferior schools and the requirement of a high school degree for admission to all schools of nursing in the country. It also led to the accrediting of nursing schools by the National
League of Nursing Education that set the standards for general evaluation. It was the responsibility of every school to apply to the committee for accreditation. The committee in turn had to judge the services and publish a list that would contain all schools that had satisfactorily
. ''""^ ' ^•'•^'^ met the criteria set by the committee "
The Association of Collegiate Schools of Nursing
The Association of Collegiate Schools of Nursing was established in 1933 and was composed of basic and postgraduate schools of nursing that were of a collegiate type and that formed a part of an accredited college or university. The association was unique in the sense that members aimed at the improvement of their programs through their own activities and not through outside accrediting 12-321-2 agencies. The objectives and aims of the group included the development of nursing education on a profes- sional and collegiate level, the promotion and strengthen- ing of relations between nursing and institutions of higher education, and the promotion of study and experimentation 182
in nursing service and nursing education. Miss Goodrich was
the first president of this association. Her work resulted
in the launching of the journal^ Nursing Research ^ in
12 • -^-^32"^ 1952.
The Brown Report
The National Nursing Council for War Service was organized in 1940 by the three national associations, and
representatives from the American Red Cross and the nursing agencies of the Federal government. This association proved to be an effective link between organized nursing schools and the Federal government and supplied an adequate number of nurses to serve the armed forces during World
War II, Toward the end of the war, the Brown Report on
Nursing for the Future was published. Dr. Lucille Esther
Brown, director of the Department of Studies in Professions of the Russell Sage Foundation, served as director of the study that resulted in the Report. The Brown Report stressed that the term professional in nursing should be used only for those who have studied in a school accredited by the National League of Nursing. Education and legisla- tion for the training of practical nurses was recommended.
The report also emphasized that all nursing schools should be nationally classified and accredited, that collegiate faculty standards should be accepted in all schools, and that a school of nursing should be affiliated with a univer-
•'"^ ' '''^-^"^ ^-^ ^^^"^ sity and ' should have a separate budget . " '
183
Auxiliary Nursing
Meanwhile, practical preparation and licensing were
being actively promoted by the National Association for
Practical Nurse Education, formed during the war under the
leadership of Hilda Torrop . In 1949, the National Feder-
ation of Licensed Practical Nurses was organized to
bring together all practical nurses who met the standards.
Gradually, the professional nurses' organizations came to
accept this nevz branch in nursing, and helped in establish-
ing its standards and in the preparation of students join-
ing it. Programs for the training of nurses' aides became
more popular and gained more acceptance among nurses.
As a result, nurses' aides began to perform many of the
errands that nurses had previously done and even performed
some of the less technical nursing procedures. Many of
these nurses' aides eventually became practical nurses when
licensing for practical nurses was instituted.
Associate Degree Nursing
Experiments in nursing education conducted by
representatives of junior colleges and of nursing educa-
tors followed later. This movement was intended to try out a combined academic and technical curriculum qualifying graduates for State registration as nurses. Teachers
College, Columbia University, took the initiative in plan- ning and conducting such programs under the direction of
Louise McManus and Mildred Montag. Community college 184
programs in nursing followed publication of Mildred Montag's doctoral thesis, Education of Nursing Technicians , written
/'-^ in 1951 = ^ The associate degree program which is widespread in the United States, offers a two-year curricu- lum in technical nursing. When this program is viewed from the vantage point of history, its contribution appears to have consisted in serving as a catalytic agent to the nursing profession in its identification of levels of preparation
. 8:3-4 for. nursing practice.^.
Restructuring Nursing Associations
As a result of rapid developments in nursing educa- tion, all the nursing associations, which included the
National League of Nursing Education, the American Nurses'
Association, the National Organization for Public Health
Nurses, the National Association for Colored Graduate
Nurses, the Association of Collegiate Schools of Nursing, and the American Association of Industrial Nurses decided to merge into two organizations. One, a somewhat reorganized
American Nurses' Association, was composed entirely of nurses- and spoke entirely for the profession. The other, the National League for Nursing, which included nurses and non-nurses, individual and corporate members, represented all those responsible for the sound development and support
^"^ ^^^"^ of nursing ' services and nursing schools . 185
Male Nurses
Trained professional male nurses functioned in the
United States as early as 1910. According to the United
States census of that year, some 7 percent of all student
and graduate nurses were men. However, the percentage
declined to 2 percent in 1940. Most men nurses at that
time were graduates of hospital schools of nursing connected
with mental institutions. Although men nurses were included
in the American Nurses' Association, special attention was
not given to them before the formation of the Men Nurses'
Section of the American Nurses' Association in 1940.^"^*^^
Men in the nursing field obviously have suffered from the
same discrimination women have experienced in other fields.
For instance, in World War II v/hen nurses had gained rela-
tive rank first and then regular rank, men nurses were kept
in enlisted grades. This discrimination was not the respon-
sibility of female nurses themselves, for in 1902 the law
organizing the Nursing Corps defined nurses as females,
and so did the law that established the Navy Nurse Corps in 1908.^=205
The changing status of the male nurse was finally
recognized by the United States Army in 1954. Also, the growing need for male nurses in the Veterans Administration Hospitals, in the psychiatric hospitals, and in general' hospitals made it easier for male nurses to find employment. Many schools of nursing started recruiting male students 186
and positions in public health, sanitation, and administra-
tion were ^ " ^"^^ made available . Also, opportunities in the
fields of anesthesia and occupational health made the field
more interesting '"^ ' "^^^ to prospective male s tudents .
At present, men nurses are- found in almost all nursing
fields, they have assumed leadership positions in national
nursing organizations by serving on the American Nurses'
Association Board of Directors and on the National League ^^^"^ for Nursing staff ' . In the future employment of
greater numbers of male nurses may contribute to solving
the worldwide shortage or nurses.
Along the same line, and as evidenced repeatedly throughout history, the struggle of nursing to be a profes-
sion has been an integral part of women's movements. Few male nurses took leading roles in the development of nursing in earlier days. Hence, the development of nursing has always paralleled influences affecting women's status. As a result it was predominantly seen and referred to as a women's profession. No doubt nursing has provided women with an early opportunity to express themselves and to ^''^ acquire education ^ = . At present, the profession is challenged to keep abreast with other professions while working for the general interest of both men and women. •
187
Nursing Services
With increasing demands on nursing services,
specialization in different nursing fields gained popular-
ity. Many more nurses were needed in clinical specialties
such as medical-surgical nursing, maternal and child
nursing, psychiatric nursing, rehabilitative nursing,
and community and public health nursing. Other specialized
areas include the military, the government health field
research, the Peace Corps, and international organizations
such as the . ''"^ ^^'^ World Health Organization ' These specialty
areas expand the field of nursing from simple nursing situa-
tions to complex care requiring a better trained nurse.
The development of the nurse clinician and the
clinical nurse specialist was a response to the growing
need for more specialized nurses. This evolving role
requires postgraduate educational preparation presently
offered '"^'^ at the master's level or beyond. ' Subspecialty
areas are also available for nurses interested in focusing
on a specific branch of nursing, such as cardiac nursing.
Nurse-midwifery is another field that is increasing in demand. The first nurse-midwifery school in the United
States was opened in 1935 and ever since many universities have offered courses on the graduate level. This came about as a result of a growing need for better antepartum and obstetrical care for mothers and newborns . ^ ^
188
In addition to the above, the Army Nurse Corps, the
Navy Nurse Corps, the Air Force Nurse Corps and aerospace
nursing were established as a result of the dynamic changes
in society which required fundamental changes in the nursing
profession. The very nature of nursing, as well as the
range of functions from simple to complex tasks that the
profession can offer have resulted in the need for more than
one kind of nurse. Besides the variety of challenging
services these nursing branches offer, the security found
in these positions has proved to be attractive to nurses.
The attractive personnel policies, complete hospital, med- ical, surgical, and dental care, health services to depen-
dents, and continuous pay increases for all grades, are some of the benefits that accompany the above positions in
' the nursing f ields .
The Peace Corps
The Peace Corps came into being in 1961 with the
objective of promoting world peace and friendship. Registered nurses were recruited from all levels to serve as volunteers or as Peace Corps nurses. This again has opened a wide gate for nurses interested in helping people
and in promoting . • ^^^"^ worldwide friendship Nurses work side by side with nurses of host countries in hospitals, rural clinics, and health centers. Other nurses assist with the clinical teaching of nursing students or auxiliary personnel. The Peace Corps has proved effective in promoting .
189
better understanding by Americans of other people's cultures
, , 15:371-2 and beliefsT .
Nursing Trends
In a dynamic society and a period of rapid change,
strain is imposed on institutions and professions. No
longer is yesterday's method adequate and no longer is the
old method of educating nurses satisfactory to meet the
demands of society. As a result, the role of registered
nurses is expanding markedly as nurses take more responsi-
bility for diagnosing and treating patients. This will
create a significant realignment of health care roles in
the near future because traditionally physicians have been
considered the only diagnostic and treatment decision makers. Factors that influence this trend have been
attributed to the progress in medical science and technol-
ogy which have expanded the range of services a physician
can perform. Advancement in science has also stimulated
interest in specialization to the extent that, at present, specialists outnumber general practitioners. This trend results in a shortage of physicians who are available for first level or primary care.
The gap created by the physician in the health care delivery system is presently filled by the physician's assistant and the nurse practitioner. The first program to train physician's assistants was started at Duke 190
University in 1965 to prepare excorpsmen in two years to
perform the less complex medical tasks. In the United
States at present, 50 accredited programs train physicians'
^ ' '''^^^ assistants who are allowed to practice in 37 s tates .
However, as early as 1962 public health nurses functioned
as nurse practitioners in North Carolina. These and others
in different parts of the country were giving primary care
in informal situations.
The role of the nurse practitioner is described as
the expanded role of the nurse and is rapidly developing
to meet the needs of the health care system. A Nurse Train-
ing Act was passed in 1971 authorizing nurses with special
^ "'"^^^ preparation to diagnose and treat patients . ' At the beginning nursing schools were reluctant to include diag- nostic content in their curricula, and nurses were worried
about the safety and morality of violating laws. Now the barrier is removed and many states have revised their
laws, breaking down the traditions and developing a momen-
tum for change.
Nurse practitioners are now licensed to carry their own practice and be accountable to their own clients for maintaining standards of practice. Pimary care provided at a satellite facility in a rural or urban area or in acute care settings, such as intensive care units where there is a need for prompt decisions on the part of the nurse, is available and represents settings where nurses can work in their expanded role."*""^^^ "
191
The American Nurses' Association has defined the
term practitioner to mean an individual who has completed
a program of study leading to competence as a registered
nurse in an expanded role whose duty and responsibility
encompass, for example, obtaining a health history,
assessing health illness status, entering a person into
the health care system, sustaining and supporting during
diagnosis and therapy persons who are impaired or ill,
managing a care regimen for acute and chronically ill
patients, counseling and supervision. ' In other words,
the nurse practitioner is presently well on the way to
becoming the family doctor of the future who will be the
gatekeeper to the health care delivery system. Health
maintenance and prevention will be the key functions of
the nurse practitioner. " ~ A general agreement exists
among nurse educators that the preparation of these nurses
should be at the graduate level and that the graduate program should be improved to include all aspects for the
"'"'^ training of nurses in the expanded role ,
As a result of the explosion of knowledge and the
development of new techniques in medicine and health care, continuing education for the health worker is being man- dated. It is only through ongoing education that the gap between knowledge explosion in health care and the delivery of improved health care services can be closed. The know- ledge explosion has required many professionals and 192
practitioners to show proof of competence and to keep their
knowledge and skills up to date."*"^
In nursing, the first National Conference for
Directors of Continuing Education was approved by the
American Nurses' Association Commission on Education in 16' 8 ~ 9 1971. In 1974, the American Nurses' Association
stated its support and assistance in the development of
state systems for the institution of mandatory continuing
education. California was the first state to pass legis-
lation laws providing continuing education requirements for
registered nurses. Licenses can only be renewed upon
submission of proof of participation in education courses.
"'•^ '•^ This law will ' take effect in July 19 78 . Many other
states are establishing similar laws.
The ladder concept, or the open curriculum, in
nursing is another trend that allows for career mobility
in the profession. Many colleges give blanket credits to
diploma and associate degree graduates with the promise
of a bachelor of science degree upon completion of some upper division courses covering an average period of one and a half years. This came about as a result of the strong support of the Regents External Degree of the Uni- versity of the State of New York that nursing at the university level should be a right to everyone and those who could not attend a college but have acquired knowledge and skills through other sources should not be denied the 193
recognition to which they are entitled. ' This concep is gaining in acceptance and has been adopted by colleges of nursing in several parts of the United States.
Another trend in nursing education is the special- ization of nurses at the doctoral level. Graduates of doctoral programs in nursing engage in consultation, research teaching, or the administration of nursing service. How- ever, they would always be high-level clinical practitioners
For example, nurse teachers should remain involved in clin- ical practice while teaching.
Nursing Research
Scientific knowledge coupled with scientific inquiry is the keystone to professionalism and further growth of any profession. Any new knowledge added to a profession has to be introduced through research. Research in nursing is developing as a body of knowledge that is expanding rapidly. Results of such progress have shown tremendous effects on the administration of patient care and will likely be the determining factor in revolutionizing the health care delivery sys.tem in the United States. In the not too distant past, much research was devoted to the improvement of nursing education and not to nursing service.
However, with the expanded role of the nurses and with the new responsibilities nurses are carrying in the hospital and community, this trend is rapidly changing and much of current research focuses on developments in nursing care and the improvement of the health care delivery system.
This impact on research was reinforced in 1955 by the founding of the American Nurses' Foundation for organized research in nursing and patient care which was endorsed by
• • 13:249-5 0 the AmericanA NursesM .AAssociation. . .
195
References
1 Abdellah, F. Nursing practitioners and nursing practice. American Journal of Public Health, 1976_, 66, 245-6.
2 American Nurses' Association first position on education for nursing. American Journal of Nursing, 1965, 65, 106-11.
3 Brand, K.L. Perils and pararrels of women in nursing. Nursing Forum, 1975^ 14, 160-74
4 Bullough, B. Influence on role expansion. American Journal of Nursing, 1976, 76, 1476-81.
5 Bullough, V. The origin of modern American nursing. Nursing Forum, 1963, 2, 13"*".
6 Bullough, V. and Bullough, B. The emergence of modern nursing. London: The Macmillan Co., 1969.
7 Day, P.E. A symposium on nursing in America: nursing history in the States. Nursing Mirror, 1976, 142, 45-8.
8 Dechow, G.H. Associate degree nursing education. Journal of Nursing Education, 1966, 5, 3-4.
9 Dietz, L.D. History and modern nursing . Philadelphia:
F.A. Davis Co. , 1963
10 Dock, L. and Stewart, M. A short history of nursing. New York: G.P. Putnam's Sons, 1938.
11 Dolan, J. Goodnow's history of nursing. Philadelphia: W.B. Saunders, 1958.
12 Frank, M.C. The historical development of nursing Philadelphia: W.B. Saunders, 1953.
13 Griffin, G. and Griffin, J. History and trends of professional nursing. St. Louis: C.V. Mosby, 1973.
14 Haase, P.T. Pathways for practice. Am,erican Journal of Nursing, 1976, 76, 950-4.
15 Jameison, E., Sewall, M. and Suhrie, E. Trends in nursing history. Philadelphia: W.B. Saunders, 1966. 196
16 Kuraraoto, A.B. Professional education and its identi- fication for continuing education. Journal of Contin- uing Education for Nurses, 1975^ 6, 8-11,
17 Nutting, A. and Dock, L. A history of nursing. New York: G.P. Putnam's Sons, 1907.
18 Peplau, H.E. What future for nursing. AORN Journal, 1976, 24, 217-35.
19 Rogers, C. The birth of our profession. AORN Journal,
1970, n, 73. .
20 Sellew, G. and Ebel, E. A history of nursing. St. Louis: C.V. Mosby, 1955.
21 Seymer, L.R. A general history of nursing. London: Faber and Faber Limited, 1932.
22 Shryock, R. The history of nursing. Philadelphia: W.B. Saunders, 1959.
23 Stewart, I. and Austin, A. A history of nursing. New York: G.P. Putnam's Sons, 1962. CHAPTER 13
LATIN AMERICA
Spanish and Portugese religious orders were
responsible for early nursing in Latin America. The Sisters
trained women of the upper-servant class for hospital and
private duty nursing. Practical teaching was mainly done
in the convents, after which the women were sent to various
private or city hospitals to learn there by practice under
physicians. The only educational requirement was that
trainees should know how to read and write. However, when
European and American residents emigrated to South America,
they established private hospitals and nursing homes to
care for their own people. Also, mission hospitals estab-
lished in South America had an influence on the foundation of
modern nursing. Moreover, the development of better nursing
care was due to the support of the medical profession and
public health officials who had been in contact with modern
developments in other countries. In company with their
efforts came the Red Cross societies to assist in establish-
ing schools of nursing and in helping other institutions, under government auspices, to recognize nursing as a pro- fession.^^217;14:470
197 198
Traditionally young women in the Spanish and
Portuguese cultures have not usually left the house to
enter professions, for they were expected to remain at home
until they were married. This allowed for the influx of
foreign nurses, especially from Britain, who introduced the
Nightingale system and organized schools of nursing similar
to that of St. Thomas's Hospital in London. As early as
1912, Dr. Carlos Nery, acting for the Department of Chari-
ties, brought several English nurses to Montevideo,
Uruguay, to start a nursing school modeled after the
Nightingale system. The English nurses remained for three years, leaving their first graduates to take over what
they had started. 7 : 218-9 ; 12 : 394
However, because of middle class prohibitions
against working women and a resistance of the middle and upper class to recognize the importance of any sort of manual labor, modern nursing was slow to develop in Latin
America. After Uruguay, Brazil was the first country to establish a school of nursing based on the Nightingale system. This resulted in establishment of the Ana Neri
School of Nursing founded by North American nurses in
Rio de Janeiro in 1923. This school was soon run by the
Brazilian nurses and in 1943 became part of the University of Brazil. Training covered a three-year period at the end of which students were sent by the Rockefeller Foundation
^^-^ -^^^"^ to ' the United States for further study . ' "
199
Other attempts to establish s.chools of nursing were
made in Peru, Argentina, Ecuador, and Chile. The govern-
ments in some of these countries took the initiative in
opening schools of nursing and in encouraging students to
apply by making available financial aid that included
scholarships to prospective students. The emphasis of these
schools, however, was on public health instruction. Red
Cross societies were also active in those countries in
establishing schools of nursing that required three years
of full-time training. Auxiliary nursing was the most wide-
spread activity of the Red Cross Schools of Nursing, which were organized to meet emergencies, administer firstaid
treatments, assist nurses in hospitals, or staff outpatient clinics. In the majority of cases, auxiliary nursing was taken up by women of good social standing who primarily worked as volunteers to satisfy a desire for service . ''''^
In 1940, the Rockefeller Foundation, the Kellogg
Foundation, the Institute of Inter-American Affairs, and the Pan American Sanitary Bureau, which later became the regional office of the World Health Organization, contrib- uted to the development of schools of nursing in Latin
America. A few of the schools were similar to the schools in the United States, while others were mainly technical in nature. Excluding the few private and Red Cross schools of nursing, Latin American governments assumed full control over most of the nursing schools that existed at the time. 200
Nursing laws in Bolivia, Chile, Ecuador, Peru, Uruguay, and
Venezuela were enacted in the 1940s which defined the title
"nurse" and laid down conditions for training. Public
health nursing was also developed under the auspices of the
government and greatly increased in demand because of its
obvious need. Many short courses of four to eight months
were given to graduate nurses interested in becoming visit- Si 392-4: 14: 470-1i,^j.xju: 25 : 156-8o mg nurses. '
From its beginning, nursing education followed the
curricula and regulations set by the government. Many
schools were located in universities but generally did not
enjoy the status of other professional schools in the same
university. Schools of nursing in Brazil and Chile were
exceptions, for their candidates had the same educational
requirements as candidates to the school of medicine. Also,
these schools integrated the teaching of social and health
concepts in the basic curriculum and furnished the leader-
ship for nursing in the Spanish-speaking world. As a result, many fellowship students from different countries joined
these schools rather than going to the United States, as was the trend then. The reasons for this influx, besides
the progress in nursing education, were the common language and the ^ ' similarity in health conditions .
As suggested above, public health programs constantly increased in number in most Latin American countries. The cooperation of the United States in these programs contrib- uted to the establishment of more centers, mainly in areas 201 where no previous public health work existed. Nursing
educators in these programs had been influential in per-
suading local nurses to seek public health nursing prepa-
ration and in developing university-based public health
schools of nursing. Many of these nurses had struggled hard
to establish this service and in the process broke many
rules; hence, they paved the way for entry to the profession
for many young women whose culture restricted their desire
to become nurses or to do any kind of work outside the
-^^ • ^5 6 home _
Through the Institute of the Inter-American Affairs,
cooperative health programs of the United States and
Latin America have developed since 1942. These programs
included physicians, sanitary engineers, nurses and other health workers who contributed to the transmission of the
American influence across the boarder. American experts
from different fields have cooperated with local natives
to establish programs in various health areas which were
later taken up by the individual countries . Such programs emphasized the prevention of disease through health teach- ing and effective treatment and care. Schools of nursing consequently adopted this approach and prevention of disease became an integral part of the curriculum. Inter-
American seminars and workshops were conducted and the
World Health Organization awarded scholarships and fel- lowships to native candidates who had the potential to
^^^""^ ' • -^^"^ " contribute to the social welfare . 202
Since considering Latin America as a homogeneous whole is impossible, speaking of nursing in Latin America in simple terms is also difficult. As a profession, nursing is only 50 to 60 years old in some countries, whereas in others it was recently introduced. Because of these variations the role the profession has played in some Latin American countries should be studied in the hope that this will provide a better view of some nursing practices in Central and South America. A study of the specific national settings will reflect the progress of the profession in Latin America. BRAZIL
Religious Roman Catholic sisterhoods were nominally
the source of supply of nurses in Brazil. Nursing was
done, however, by uninterestd persons, males and females,
who frequently were patients themselves, and who showed
^ " interest in their fellow patients . In 1921
physicians in the National Department of Health first
became conscious of a need for trained nurses. As a result.
Dr. Carlos Chagas visited the United States and requested
the cooperation and assistance of the International Health
Board. To adapt the North American system to the needs of
Brazil, a Service of Nursing was established in the
National Department of Health with equal rank with the other
bureaus of the department. Brazil was the first country in
the world to establish such a bureau in the National Depart- •'^•^^^ ment of Health.
The Development of Schools of Nursing
Under the direction. of this service, schools of nursing were established as annexes to the hospitals.
Only students whose personal qualifications were of the highest order and who had a normal school diploma were accepted. The course covered a period of two years and four months and included theoretical as. well as practical work. One of the first schools to be started was the
203 204
Anna Nery School of Nursing which was, as mentioned above, 28 266 founded in 1923. ' In order to provide students with
a well-rounded experience in theory and practice, the
length of the nursing course was extended in 1928 to three
years. With the help of the Rockefeller Foundation, many
graduates of this school, were sent to the United States to
be prepared as leaders of the profession. These graduates
later replaced staff from the United States in operating the
schools of nursing.
By 1925 graduates of the school felt the need for
organization to further the development of the profession.
This resulted in the formation of the National Association
of Brazilian Graduate Nurses. This association was granted
membership in the International Council of Nurses in 1929
and for the first time became a part of the world nursing
service. Its journal is called the Revista Brasiliera de
n 25:422 Enfermagen.
A decree regulating the profession of nursing was
signed in 1931 by Dr. Vargas, then Chief of the provisional
government of Brazil. As a result, the title of graduate nurse was given only to graduates holding diplomas from official schools recognized by law. The direction of the school of nursing was placed under Rachel Haddock Lobo, a nurse who had taken a postgraduate course in the United
States and had had experience in administration and instruction in Brazil. This step was a victory the nursing
'^'^^ profession " had long struggled to achieve . .
205
Nursing at the University Level
- Ten years after the Anna Nery School was opened,
Dr. Carlos Chagas inaugurated the second school of nursing,
Escola Carlos Chagas, founded on the same pattern as the
Anna Nery School. For that decade the Nursing Association
in Brazil had struggled to place the school in the univer-
sity, and by 1934 another decree was issued by the govern-
ment authorizing the organization of a School of Hygiene
and Public Health within the university and placing the
Anna Nery School within it. " ~ In 1942, the Anna Nery
School of Nursing became an independent university
, 1 5:576 school
The gradually changing concept of nursing functions
and the entrance of well-educated young women from families
of high social status into the profession, exerted a great
deal of influence on the social status of the profession.''"
Also the requirement of university- level entrance examina-
tions for those entering the school of nursing had a sig- nificant effect in changing the profession's social status.
In addition, hospitals and administrators at the public and private sectors, recognizing the difference in the quality
of nursing care given by trained versus untrained nurses,
raised salaries, another factor that made nursing more
^''^ ' ^ " ' appealing to many educated young women . 206
Nursing Education
In 1949, a federal law was enacted which established
two levels of nursing education: a basic three-year program
requiring secondary education for admission, and an eighteen-
month program for practical nurses for which only practical
training was required. This law also provided for accredi-
tation of both schools of nursing and assured their fund- 5 5 7 8 ^^S>- ' An integrated national system was later adopted
which included courses at three levels. The highest level
professional nursing schools (that is, university schools),
with a four-year curriculum and regular university entrance
requirements, prepared nurses for leadership and teaching
positions. At the middle level the technical nursing
schools prepared diploma nurses. The auxiliary schools
constituted the lowest level. The government in its plan
assured the progress of the individual from one level to the
other through ^ ' additional preparation .
Postbasic and postgraduate programs in nursing education are presently available in different areas of nursing specialization such as nursing education for nurses interested in becoming teachers, nursing school administrators, nursing service administrators, and public health nurses. All the above listed specializations are acquired within a nine-month period at a specialized insti- tution. The nurse-midwifery diploma is also available at the postgraduate level and requires one year of work in public health, obstetric and pediatric nursing, and social 207
welfare. ' This progress in nursing as a profession has changed the image of the nurse, according to a recent
Brazilian survey, to a highly positive one. Nursing stu- dents in the country attribute to the nurse the duties, aspirations, and values that reflect a high degree of
7-220' ^ commitment and dedication to the profession. • COLOMBIA
The Development of Schools of Nursing
As early as 185 7 many hospitals were founded in the
different parts of the country by French Sisters who settled
in Colombia at the time. This movement was later followed
by other religious orders, the most influential of which
was the Order of St. Vincent de Paul. In 1903 Dr. Jorge
Calvo, upon his return from a visit to Europe, founded the
first school of nursing in Catagina. His admiration of the
nursing system there led him to the establishment of the
school of nursing at St. Clara Hospital. In 1913 professor
Jose Ignacio Barberi, founder of the Children's Hospital,
established another school of nursing.
The first semi-official organization for the educa-
tion of nurses was founded in 1924. As a result, a school
of nursing was founded in collaboration with the faculty of
medicine. The program offered by the new school integrated
theory and practice, lasted for two years and required
primary education for admission. This school ceased to
-"--^ "''^''^ exist in 1937 . •
The Red Cross in Colombia took the initiative in
1919 in bringing a Belgian nurse— Madame Ledu—who initia-
ted modern nursing in Colombia and recruited ladies of higher socioeconomic class to join the profession. In 1929,
the National School of Nursing was founded with the help of
208 209
the Rockefeller Foundation, and contributions of North
American nurses. Professor Jose Maria Montoya was assigned
by the Colombian government to head the newly founded
school. The National School of Nursing offered two pro-
grams: one prepared nurses for staff nursing positions;
the other prepared nurses who worked in the health and
• • I 13:1076-7 social1 assistance^ fields^r- 1 throughoutu ^ the country.^
The Red Cross of Colombia established another
school in 1938 to prepare nurses for administrative posi-
tions in hospitals and clinics. The Red Cross School was
the first in the country to accept student residents.
This opened the way for many candidates from different parts
of the country who were interested in the profession.
The program adopted the American Red Cross principles in
preparing nurses to work in wars and natural disasters.
As a result, nurses had their practical experience in
military hospitals while their theoretical preparation
stressed military health, orthopedics, kinestherapy , and
legal medicine.
With the coming of World War II, the United States
government cooperated with the governments of America to
expand the principles of world health by fighting infec-
tious diseases. As a result, the Inter-American service of Public Health established a college of nutrition and a normal superior school of nursing which were incorporated in the National University in 1943. The school of nursing 210
was under the direction of Helen Wjouit, a North American
nurse. The school was sustained by the Government of
Colombia, the Government of the United States, the
Rockefeller Foundation, and the Office of the Pan-American
Health. The program was based on that of the North Amer-
, . . 13:1079 lean schoolsT of nursing.
Nursing Education
Professional nurses and auxiliary personnel are
responsible for giving nursing care in Colombia. As early
as 1903, university schools of nursing provided basic nurs-
ing education for nurses. At present admission requirements
to all schools of nursing are consolidated and include high school completion. The academic university system was
adopted in 1963. It placed nursing students on the same
level as students in other faculties. The four-year program now culminated in the degree of Licentiate in Nursing Sci-
ences. This program focuses on the natural and social sciences, the humanities, and integrates nursing theory with practice. This is in contrast to nursing education in the past which stressed the development of skills and 23:37 bedsideu A -A care.
Continuing education in psychiatry, administration of nursing service, and public health have been developed by the National University of Colombia. Specialization in maternal-child health, psychiatric, and medical-surgical 211
nursing is available at the master's level in most univer-
sity schools of nursing. Since all the courses are offered
in Spanish, which is needed for administrative and teach-
ing positions, the nursing shortage has decreased greatly
in Colombia as well as in other Latin American countries.
For economic and language reasons Colombian nurses are
taking advantage of these studies that they cannot get in
other countries.
The development of nursing in Colombia has been
aided all along by motivated members of the profession,
various international organizations such as the World
Health Organization, the Kellogg Foundation, the Agency
for International Development, and the Rockefeller Founda-
tion .
Basic Nursing Education
All schools of nursing in Colombia are approved and
controlled by the Ministry of Education through the Colombian
Institute for the Improvement of Higher Education. This
institute is responsible for accreditation of schools of nursing, the revision of curricula, and the implementation of nursing education policies. On the other hand, the
Ministry of Health cooperates with the Ministry of Education in administering the schools of practical nursing . ''"^ " ''"'^
However, since 1969, the National Association of University
Schools of Nursing has been operated as the consultant agency to the Ministry of Health. It has developed many 212
activities toward the maintenance of the quality of nursing
curricula and instruction. Within the university setting,
the schools of nursing function as autonomous units with the
mam responsibility endowed on a nurse-administrator.
Nursing Programs
Nursing education in Colombia is on two levels: the professional and the auxiliary. Professional nursing is
taught in three programs in the university:
(1) postgraduate or magister,
(2) Licenciatura or the Bachelor of Science
in Nursing (B.S.N.) , and
(3) general nursing.
Auxiliary nursing, on the other hand, takes place in inde- pendent schools, schools annexed to hospitals, sectional health services, or vocational educational institutes.
Auxiliary or subprofessional nursing has three divisions:
(1) practical nursing,
(2) aides in nursing, and
(3) health promoters.
Graduate programs offer master's degrees in maternal and child nursing, mental health and psychiatric nursing, medical and surgical nursing, public health nursing, admin- istration and nursing education, administration and nursing services. Also, short courses in community nursing, maternal and child nursing, psychiatric nursing, midwifery, and epidmiology . ^"'^ are offered at the graduate level ' 213
The Licenciatura or B.S.N, program is four years or eight
academic semesters and is offered in nine universities
throughout the country. The general nursing program,
equivalent to the diploma program in the United States,
requires three years or six academic semesters of study.
Contrary to the trend in the United States, the diploma
program in Colombia has been flourishing, a measure attrib-
uted to the need for more nurses in this Latin American
-^^15 • ^4-5 country. •
Thirty-two schools for auxiliary nursing presently
function in Colombia. The practical nursing program requires
eighteen months of study, including six months of on-the-job
practice. Nurses' aides are prepared in hospitals over a
three-month period according to the institution's needs.
The health promoters or Promotoras de Salud are agents pre-
pared through a three-month program to give primary care in rural communities.
Candidates for the university nursing program should
have five years of primary and six years of secondary edu-
cation and must pass university entrance examinations to be
accepted. Candidates for the practical nursing programs
should have finished two to four years of secondary educa- tion, and pass the entrance examination and interview.
Nursing aides are also required to have completed two years of secondary education. The Promoters of health are re- cruited from their own communities. Interest in working 214
with their own people, a minimum of five years of elementary education, and the ability to pass the entrance examination are requirements for admission to the programs. No age limit is set for the candidates to the professional programs.
However, 18 is the minimum age recommended for auxiliary 15 '6-7 personnel. ' Students in the auxiliary nursing programs pay no tuition fees, whereas students in the professional programs pay tuition according to scales established at the
15 • 7 respective universities in the country.
No unified curriculum for university nursing programs exists in the country. However, most universities have common criteria in the organization of their curricula.
Courses include general, social, basic medical, and nursing sciences. The schools organize the content matter to meet
15 • 8 the needs of the areas they serve.
Nursing Services
The organization of nursing services in Colombia is shown in Figure 4. 215
Nurse Coordinator - 0) > Associate Committees
u Nursing Teams Nursing Teams C u Medical Care Human Resources
Head of Medical Care
Nurse Coordinator 0) > Coordinating (1) i-j Committee
0) u d Assistant Coordinator Assistant Coordinator > Hospital Services o Outpatient Services u
Technical Committee of Nursing
Nurse Coordinator
0) > Assistant Coordinator 0) Assistant Coordinator J Hospital Services Outpatient Services
C o Head Nurses Practical Nurses •HM Clinical Units Nurses Aides OJ Practical Nurses Health Nurses' Aides Promoters
Head Nurses X) 0) c > Practical Nurses Nurses' Aides
O ^-1 J 3 Health Promoter (
Figure 4. Nursing Services in Colombia.
Adapted from: Ministerio de Salud Publica. Estudio nacional de la situacion de enfermeria en Colombia. Republica de Colombia, 1972. = ,
CUBA
Health Services
Before the revolution of 1959, the social and
economic conditions and the health patterns of the people
of Cuba were comparable with those of other parts of
Latin America. At present, although scarcity of health
manpower exists, the health of the population of Cuba is ''-^^'^ better than elsewhere in Latin America. Primary health
care in Cuba is made available to practically the entire
population, in contrast to nonexistent health services in
rural areas befo re 1959. Health policies and programs
emphasize aspects of preventive, rehabilitative, and cura-
tive medicine, the planned collaboration between profes-
sional, auxiliary, and volunteer personnel, and active
participation by the community in the arrangements of the
. ^ ' health services •
The Ministry of Health in Cuba is responsible for
the Cuban health policy, and for health administration,
planning and supervision. Primary, secondary, and
tertiary care are. available to the Cuban people at poly-
clinics, regional hospital centers, and provincial hos-
pital centers respectively. Nurses at the different care
levels are grouped according to their specialties — adults
children, and public health. All health workers in Cuba belong to one union regardless of their level of training or discipline. 1 7 • ? S 216 217
Nursing Education
Nursing education is three-and-a-half years in
length and requires completion of nine years of primary and secondary education. General education is integrated with nursing courses so that on graduation the nurses are at the preuniversity level. Most clinical experience of student nurses is in general or specialized hospitals with a limited amount of experience in polyclinics and rural sections. Following graduation, the nurse is assigned to a special area of need for one or two years.
Postbasic education is available at the National
Teaching Unit which offers courses in epidemiology, nutrition, sanitation, and health services administration. For nurses, courses in obstetric, pediatric, and adult nursing are offered along v/ith administration and teaching. University- level nursing education is not yet available in Cuba although some efforts are being made to establishing a university-
1 7 28 based degree program. MEXICO
For centuries nursing in Mexico was carried on by
sisterhoods and brotherhoods of the Catholic church.
However, about the middle of the eighteenth century, the
political revolution brought with it a decrease in the number
of churches and consequently in the number of church offi-
cials, leading to a neglect in nursing practice. Nursing
was taken over by the university of Mexico in 1911 and both
nursing education and midwifery were placed under the super- 7-20-1 vision of the medical school. 2
Modern nursing in Mexico, like that of other Latin
American countries came about as the result of cooperation
among nurses, the government, and other national and inter-
national agencies such as the League of the Red Cross
Societies, the Institute of Inter-American Affairs, and the
Rockefeller Foundation. Of the above-mentioned groups, the
Red Cross was responsible for introducing basic nursing edu-
cation at the time of World War II. The Red Cross School
of Nursing and the University of Mexico School of Nursing
are the best known schools among many of those that offer
basicu • courses m• nursing.. 26 429
In 1935 the University of Mexico School of Nursing, with the help of the Rockefeller Foundation, initiated the
first graduate course in public health nursing. In addition,
scholarships and fellowships were awarded by the Rockefeller
218 .
219
Foundation to Mexican nurses for study in the United States.
Some graduate nurses were also sent to the United States
for one-year courses in administration, supervision, and
• 26:429-30 . . . t- T ^ teaching in hospitals and schools of nursing.
Mexican Nurses Association
The Mexican Nurses' Association became a reality
in 1947. Its goal was to promote the educational and
professional progress of Mexican nurses, translating this
progress into better care for individuals, well and sick,
thus fulfilling the role that present-day society requires
of nursing. The Association was also interested in promot-
ing and strengthening the bond between Mexican and foreign
groups and maintaining a relationship with the International
Council of Nurses. Following in-depth studies, the Colegio
National de Enfermeras was founded. It is a corporation of
public right created by law, representing professional
nurses before the public powers and authorities. The
Colegio has intensified the goals set by the Mexican Nurses
Association
The Colegio National de Enfermeras offers, not only
to those who practice the profession but also to those who
receive its benefits, all the advantages derived from such
a status which is reflected in the improvement of health
• ^- 16:370-3 care of^ the Mexican population.1 220
References
1 Bareira, I. Changes in the image of the nurse in Brazil International Nursing Review, 1976^ 22, 43-7.
2 Beck, P. Impressions of a visit to Latin America. International Nursing Review, 1959, 6, 53-9.
3 Bullough, V. and Bullough, B. The emergence of modern nursing. London: The Macmillan Co., 1969.
4 Chagas , A. Modern nursing in Latin America, American Journal of Nursing, 1953j 53, 34-6.
5 DeAlcantara, G. Nursing in Brazil. American Journal of Nursing, 1953, 5Z, 576-9.
6 Development of nursing service in Brazil, American Journal of Nursing, 1922, 22, 560.
7 Dock, L. and Stewart, M. A short history of nursing. New York: G.P. Putnam's Sons, 1938.
8 Goodnow, M. Nursing history (9th ed.). Philadelphia: W.B. Saunders, 1955.
9 Guanes , H. Nursing education in Brazil. International. Nursing Review, 1958, 5, 32-3.
10 Hentsch, Y. Nursing in Latin America. American Journal of Nursing, 1943, 43, 440-2.
11 Jackson, J, Nursing in Brazil. American Journal of Nursing, 1901, 2, 56-7.
12 E, M. and Suhrie, E, Trends in Jameison, , Sewall, nursing history. Philadelphia: W.B. Saunders, 1966.
13 Jaramillo, A. A. Historia y desarrollo de la enfermeria en Colombia. Revista de la Faoultad de Medicina, 1948, 17, 1075-9. (Spanish)
14 Jensen, D.M. History and trends of professional nursing St. Louis: C.V, Mosby, 1955.
15 Ministry of Health, Colombia. Nursing in the world, 1976. Unpublished manuscript. (Available from the Ministerio De Salud Publica, Republica De Colombia), 221
16 Moreno, G.T, Mexican Nurses Association: change for development. International Nursing Review, 1972_, 19, 370-6.
17 Mussallem, H.K. A glimpse of nursing in Cuba. Canadian Nurse, 1913, 69, 23-30.
18 O'Hara, H. Public Health Nursing in Latin America. Public Health Nursing, 1950, 42, 73-8.
19 Parsons, E. Modem nursing in Brazil. American Journal of Nursing, 1921, 27, 443-9.
20 Ponte, M.L. A rapid glance at Brazilian postgraduate education. International Journal of Nursing Studies, 1967, 4, 37-46.
21 Progress in nursing education in Latin America. Inter- national Nursing Review, 1961, 14, 64.
22 Pullen, B. Nursing in Brazil. American Journal of Nursing, 1935, 35, 345-50.
23 Restrepo, R. Nursing in Colombia. Canadian Nurse, 1969, 65, 31.
24 Sellew, G. and Ebel, E. A history of nursing. St. Louis C.V. Mosby, 1955.
25 Seymer, L.R. A general history of nursing. London: Faber and Faber Limited, 1932.
26 Stewart, I. and Austin, A. A history of nursing. New York: CP. Putnam's Sons, 1962.
27 Vasquez, S. Nursing resources in Mexico. International Nursing Review, 1913, 20, 20-4.
28 Wood, B. Nursing in Brazil. Nursing Times, 1928, 24, 266-7. PART V
ASIA
.4 CHAPTER 14
LEBANON
In early days when sickness, or a confinement
occurred in any of the families in Lebanon, one of the more
experienced women of the community, or the mother, sister,
cousin, or aunt, cared for the sick as best as they could.
The old midwife had considerable influence on the care of
the sick, especially if the patient was a woman or child.
Lack of nursing personnel constituted a great difficulty in
the care of the sick. Although the work of Florence
Nightingale in the Crimean War and her contributions to the
development of modern nursing were known to the Lebanese people, a long time elapsed before nursing was established
^^'''^ and recognized as a prof ession. ^ "
A simple form of nursing was begun in Beirut in
1847 by the French Sisters of Charity of the Order of
St. Vincent de Paul.''' They ministered to the sick in a small hospital attached to their convent. In 1860 the Prussian
Knights of the Order of St. John built a hospital in Beirut which was later called the French Military Hospital. In this hospital nursing was done by German Deaconesses of the
Kaiserwerth Sisterhood who later trained some Lebanese and
223 224
Syrian nurses to serve as assistant nurses in their hospital.
These episodes marked the beginning of nursing in that part ^^^^^^-6 of the world.
The Beginning of Modern Nursing
Modern training of nurses in the country was the
outcome of the school of nursing which was established in
1905 in connection with the American University of Beirut."'"^
The school has been the center of training for Syrian and
Lebanese probationers, whose certificate was recognized for
higher posts. Previously a few isolated nurses were found who were either foreigners or Syrians . Some of these nurses received their training abroad while the rest were
'"^"'"^ ' '^^^ ^ * ' ^ trained by missionary hospitals in the country .
Adla Wartabet was one of the first nurses to come
to Beirut after receiving her degree under the Nightingale
system in England. In 1900 she took charge of the Greek
Orthodox Hospital of St. George where she served for three years. Many other Lebanese nurses went abroad to study nursing as early as 1875, with the aim that on their return they would start a school to train nurses in Lebanon and hence render service to their own people. Evidently, a great need for a school of nursing existed and this was met by the inauguration of the American University of Beirut
School of Nursing. The school was designed to meet the needs of Asia Minor, Syria, and Egypt for the education of nurses. 225
Jane E. Van Zandt, a graduate of the New York Postgraduate
Hospital, was put in charge of the school. A Mrs. Dale
was appointed superintendent of the hospital and hence
was responsible for the clinical part of the instruc- tion.6--1518;7:1063
The enrollment of the Lebanese at the school was not
high for several years because parents preferred that their
daughters remain at home or marry and considered the young
women's dignity to be lowered by serving in a hospital. Als
the need of education for young Lebanese women early in the
century was not generally recognized. However, if a girl
needed to earn her living, teaching was almost always pre-
ferred. This situation brought many young Armenian women in.
Educated in orphanages, or by relief funds, as refugees in
^^'^ ^ ' Lebanon they needed to work for a living .
The first three-year program required an elementary
education and some knowledge of English for admission.
Instruction was in English by professors of the College of
Medicine. In 1928, the school adopted the same standards for nursing education that were developed in New York State and in 1932 a high school diploma was required for admission into the School of Nursing. This change resulted in approval of the school by the New York State Board of Nurse Examiners of the State Education Department which later led to its approval by ^ '"^^ the Lebanese Ministry of Education . " 226
Nursing Education
The American University of Beirut School of Nursing
offers two programs, a diploma in nursing, which is being
phased out, in line with recent developments in nursing, and
a bachelor of science degree. The Bachelor of Science pro-
gram began in 1936 as a two-year liberal arts curriculum
followed by three years of nursing. This program was changed
in 1964 to offer an integrated course of study in nursing,
science, and liberal arts over four calendar years. Lebanese
students should have the government certificate, Baacalaure-
ate Part II in Science, to be accepted. This reduces the
program for them to three years , for the government certifi-
cate is equivalent to a university freshman level.
In 1952 two postbasic programs for diploma graduates
were established at the American University of Beirut School
of Nursing to serve the needs of graduate nurses from Middle
Eastern and African countries. One program focuses on public
health nursing and the other prepares teachers and nursing
service administrators with clinical specialties in medical-
surgical, maternal and child health, or psychiatric nursing. A third program was recently started for nurse midwives seek-
^-^^ ing preparation ^ • as tutors in midwif ery .
Between 1933 and 1973 other nursing schools were established, mostly private. Eleven schools presently prepare professional nurses. Nine are private, one is government, and one is a program in psychiatric nursing. 227
Only two of these programs lead to a Bachelor of Science degree and a license. They are offered at the American
University of Beirut and the French University respectively.
Throughout the country nursing classes are held in Arabic,
English, and French. A constant exchange of ideas between the schools is made possible through regular meetings of the directors of the schools or through frequent seminars and ^ ^'^^ workshops to study problems facing nursing educators . "
Instruction in all the schools is done by nurses who are responsible for classroom and clinical teaching, providing a continuity for the learner. However, physicians are invited frequently to lecture on topics in medicine.
The fact that nursing textbooks are mainly available in
French and English puts a limitation on student nurses who are not fluent in either language.
Nursing Programs
The country now has three programs of nursing.
The first is the university-based professional nurse program which requires students to have passed the Baccalaureate
Part II certificate, the government examination. The second program is based on the Ministry of Education Law passed in
1966 which requires a minimum of eleven years of general education followed by three or more years of nursing educa- tion in a recognized school of nursing and which leads to a diploma in nursing. The third program is more recent and 228
came about as a result of the 1968 Ministry of Education Law which established a technical nurse program similar to the pattern of European technical programs. The student in this program enters with ten years of education and the Brevet
Certificate, a government certificate, and receives the tech- nical Baccalaureate Part I in Nursing. At the end of two years of general education, science, and nursing, followed by a government examination, the Technical Baccalaureate Part II
1 ^ ' ^^"^ 4,8.140 in Nursing is granted .
The French Faculty of Medicine School of Nursing was established in 1938 as a school for midwifery and nursing.
It was separated in 1942 into two schools, one for midwives and the other for general nurses. The Baccalaureate Part II certificate is required for entry to the school which offers a three-year program at the end of which the student receives the 'license" in nursing. In the year 1945, the Red Cross
School of Nursing was founded in Beirut. It requires its students to carry the Baccalaureate Part I certificate.
After three years in nursing and general education studies, the student has to sit for the Technical Baccalaureate
"'•^'"^ Part II examination.^-
Practical nursing programs, varying from six months to one year, are offered at the American University Hospital, the Red Cross, the National School of Nursing, and H6tel Dieu.
The student is required to have the Brevet certificate for entrance. These programs have contributed to better nursing care than that previously done in most hospitals by aides. 229
Graduate- level nursing education is still lacking in
Lebanon. Present efforts concentrate on establishing a
Masters of Science program at the American University of
Beirut. Nurses who wish to pursue graduate- level education
currently go to the United States or Europe. Continuing edu-
cation is a growing field in Lebanon and Lebanese nurses from
different schools cooperate in planning seminars, workshops ^ and short "'''^^^ refresher courses for nurses in the region . "
Besides the general nursing courses in different
nursing schools in Lebanon, a three-year course in psychiat-
ric nursing is offered at the Lebanese Hospital for Mental
and Nervous Disorders. This hospital, which is unique in the
Middle East, was established in 1900 by Theophilus Waldmeier, a pastor and missionary. Training of students was in English, and later a course in Arabic was started. This school admits students who are sent by their governments from different countries in the area. Standards of training followed the
British system at the beginning but were changed gradually to meet the country's nursing needs.
The Maternity and Child Health Center was opened in
Beirut in 1951 as a result of an agreement between the gov- ernment of Lebanon, the World Health Organization, and 2 UNICEF. With the plan to advance maternity and child care in the area, Mary Mangos, a World Health Organization Public Health Nurse/Midwif e , was assigned to the center to help the
Lebanese staff in the training of maternal and child health 230
nurses. The work done by the nurses in the maternity field
proved to be effective in promoting the health of mothers and children. 3
Nursing Organization
In view of the tremendous complexity with regard to
nonprofessional groups in the nursing profession who were
licensed at an earlier time, Lebanese nurses are still strug-
gling to establish an association that will group the grad-
uate nurses together. The establishment of such an order would require all registered nurses to join in order to
practice and will help in the development of nursing as a profession in the country. Nurses representing the various
schools that form the Central Committee of Nursing are cur- rently working with the Ministries of Health and Education
to speed up the process. Membership in the International Council '^^ of Nurses was granted to Lebanese nurses in 1969 '
Nursing Conditions
About 95.5 percent of the registered nurses in
^"^^ Lebanon in 19 70 were f emales. ^ ' At present more male nurses are being trained, but many of them migrate to work as nurses in neighboring Arab countries where the pay is greater. Many female registered nurses in Lebanon are not actually practicing nursing. Some marry and leave their jobs while others emigrate to other countries where working conditions are more appealing. This leaves the country in 231
constant need of more trained nurses. To attract the inactive group of nurses back to the profession, the government has been working on better salary scales, fringe benefits, and working hours as a step in meeting the needs of the people. 232
References
1 Cardwell, V. Public health nursing in Lebanon. Public Health Nursing, 1943, 55, 430-4.
2 Edwards, M. Health services in Lebanon. Nursing Times, 1964, 60, 848.
3 Mango, M. British nurse-midwife with WHO. Nursing Mirror, 1954, 99, iv-v.
4 Mitchell, A. Unique mental hospital in the Middle East. Nursing Mirror, 1954,55, viii-ix.
5 Rifka, G.E. Nursing manpower in Lebanon. International Nursing Review, 1970, 17, 195-205.
6 Shahla, S. Nursing in Syria. American Journal of Nursing, 1930, ZO, 1515-8.
7 Stevens, E. Nursing in Syria. Nursing Times, 1927, 23, 1063.
8 Thomas, G.M. Nursing in Lebanon. International Nursing Review, 1975, 22, 138-43.
9 Van Zandt, J. A training school of nurses in the Turkish Empire. American Journal of Nursing, 1909, 9, llh-e.
10 Watt, C. Visiting eleven countries. Nursing Times, 1950, 46, 761-2. CHAPTER 15
ISRAEL
Israel, formerly called Palestine, had several mission
hospitals under German deaconesses, French religious sisters,
Scotch, and English nurses. Some young Palestinian women
studied nursing but the majority were secluded and seldom
showed interest in a profession that was not highly regarded
' ^'^^ ^ = the = by public . In 1912, a small group of Jewish
women in New York, organized under the name Hadassah, took
an interest in the health conditions in Palestine and as
a result sent two American nurses to Jerusalem early in 1913.
These nurses devoted themselves mainly to maternity work,
which included organization and supervision of midwives, and
to district visiting nursing.
Most of the welfare activities in Palestine before
World War I were maintained by foreign agencies. During the
war many of these agencies ceased to function and as a result
a number of hospitals were closed. Toward the end of the war, health conditions became desperate due to famine, the
primitive sanitary conditions, and a shortage of physicians
and nurses Epidemics of infectious diseases spread over
the country killing and disabling many people. Following an appeal by local authorities, Hadassah sent to Palestine a unit of physicians, nurses and sanitary engineers with a large supply of drugs. This unit in 1918 opened hospitals and clinics in Jerusalem, Jaffa, Tiberias, and Safad and 233 234
expanded rapidly into a countrywide system that included
dispensaries, health welfare centers, and other allied
, , 6:1093-4;13:722 educational1 and preventive activities.
Under direction of a Dr. Finley, the American Red Cross
society sent a medical and social service unit to Palestine 12-370 to meet the devastating hospital needs of the country.
The Beginning of Nursing Education
The Hadassah School of Nursing was established within
three months of the arrival of the medical team in Palestine.
The school was attached to the Rothschild Hospital of Jeru-
salem and offered a three-year nursing course. The studies
included anatomy, materia media, theory of nursing, dietet-
ics, bacteriology, hygiene, and medical-surgical, obstetric
and pediatric nursing. Clinical training in each of the
nursing areas was carried in the various hospitals of the
country and extended over a period of three months . The
Gymnasium, a high school diploma, was required for admission,
''"^'^"^ ' '"'^^^ as well as fluency in the Hebrew language ' ^
Each year, a postgraduate course was offered in public health nursing to graduate nurses who showed interest
in pursuing further study and aptitude in the work. The
course included district maternity nursing, prenatal and postnatal care, infant welfare and preschool nursing, and tuberculosis nursing. Many nurses were also sent to the
United States to specialize in teaching and administration .
235
nurses had so that they could take over when the American 6:1095;13:721-2 to leave
Between the years 1934 and 1946, seven schools of mean- nursing were operating under Hebrew auspices. In the Gov- time the Department of Health of the British Mandatory
ernment had opened hospitals for the Arab-Palestinian pop-
ulation. British- trained nurses headed these hospitals
and conducted short nursing courses to teach local young women nursing and midwifery. As a result, the standard
colonial nursing curriculum was introduced to these hospi-
• 7:162; 14:880 tals^1 in Palestine.T> ^ ^-!^^
When Israel was formed in 1948, Israeli nurses
stepped into administrative and teaching positions and the
new Ministry of Health established a division of nursing
with a Hadassah graduate nurse to head it. Nursing leaders
were then trying to establish standards for nursing care
and nursing education, especially after the great influx of
refugees who claimed to be nurses but who had no documents
to prove it. The International Council of Nurses, through
a London office opened to help war-torn nurses establish
their identity, helped the nurses of Israel by cooperating
closely with the nursing division in the Ministry of Health
to verify the nursing education that the new immigrant
nurses claimed to have. Israel became a member of the 1 6 5 8 International Council of Nurses in 1965. 236
Nursing Education Today
Today 17 schools of professional nursing in Israel
offer a three-year hospital program comparable to the diploma
program in the United States, Public health nursing is
greatly emphasized in the curriculum of these schools for it
is viewed as one of the most important functions of nurses.^
Work and study at community health centers comprise an
integral part of the curriculum. Also students are given the
opportunity to observe families in their homes and study the
dynamics that affect the family's structure. At completion
of the three-year program, students are awarded the diploma
of State Registered Nurse. Postbasic educational programs in
public health nursing, midwifery, operating room techniques,
and mental health nursing are available to nurses who wish
to pursue higher education. The programs are six months to one year long, depending on the area of study, and graduates
'"^ ' become specialists in their own f ields ' =
A program leading to the baccalaureate degree in nursing was recently started at the Hebrew University to include two years of academic study in chemistry, biochem- istry, physics, sociology, anatomy and physiology, social welfare, and occupational therapy. During this time intro- ductory courses to nursing practice are given, accompanied by ward visits once a week. This is followed by two years of nursing courses and internship in a specialty area.
In order to deal with the problems of staff advancement 237
that might accompany such a program, the director of the
school of nursing equated ten years of head-nurse experience
9-23' with bachelor's degree.
Practical nursing programs are also available in
Israel and usually admit students who have finished eight
years of schooling. The program is 18 months in length dur-
ing which students are trained to do simple nursing proce-
dures and to assist graduate nurses in carrying out the unit
work. Programs to prepare nurses' aides are also available
"'"^ ^^"^ ' throughout the country .
Kibbutz Nursing
A typical feature of nursing in Israel is the Kibbutz
nurse who works in a Kibbutz and is a member of it. The
nurse could have joined it voluntarily, married into it, or
have been born to it and hence sent by it to a nursing
school. Her main functions include general and public health
nursing which are offered in the framework of her community.
Like other members, the nurse lives on a collective farm
sharing the work, income, and general activities of the
Kibbutz. Such a nurse covers the full range of nursing from
"'"^ '"''^^ clinic work " to bedside care and health teaching .
Nursing Organization
Most professional groups in Israel, including the
National Association of Nurses in Israel (NANI) , are members of Histadrut, the National Labor Organization. NANI is the 238
negotiating body for wages, hours of work, and working
conditions. Activities such as curriculum planning and
nursing legislation are the responsibilities of the Ministry
of Health with which NANI participates and has a great deal
of influential power. Nursing communication with other
professional associations is facilitated by joint member-
ship in the Histadrut. Various professional groups meet
regularly in service team conferences and cooperate on health
matters. The medical group tends to be paternalistic in
Israel as in most other countries. However, nurses are
struggling to overcome this subservience and antagonism to
the medical staff and to cooperate on an equal level. In the
health service organizations, nursing is in a good position
to communicate effectively, due to the availability of nurs-
ing leadership at every level, including the Ministry of Health. 2=28-9;3
Primary Health Care
In the overall delivery of health care services, outpatient care is stressed. Minor surgery and complicated treatments are performed on an outpatient basis, due to the proximity and access to these facilities. Moreover, commu- nity health centers located in every part of the nation stress prevention, provide maternal and child care, and offer different services depending on the needs of the community. Public health nurses do home visits to educate the family on 239
the importance of prevention and on the availability of outpatient facilities are equipped to meet their primary
, 4:20-2 care needs. 240
References
1 Bergman, R. Israel's educators in the diploma schools of nursing. International Journal of Nursing Studies^ '1971, 8, 103-26.
2 Bergman, R. Nursing and organized groups in society. International Nursing Review, 1965, 12, 28-31.
3 Bergman, R. Opinion on nursing. International Nursing Review, 1911, 18, 195-230.
4 Bergman, R. Opinion on nursing. International Nursing Review, 1976, 23(1), 15-24.
5 Bergman, S. Team nursing in public health Israel. International Journal of Nursing Studies, 1965, 2, 261-7.
6 Bluestone, M. The Hadassah School of Nursing. American Journal of Nursing, 1928, 28, 1093-7.
7 Cantor, S. Nursing in Israel. American Journal of Nursing, 1951, 31, 162-3.
8 Dock, L. and Stewart, I. A short history of nursing. New York: G.P. Putnam's Sons, 1938.
9 Golub, S. Nursing in Israel. Nursing Mirror, 1973, 1S6, 22-5.
10 Goodnow, M. Nursing history (9th ed.). Philadelphia: W.B. Saunders, 1955.
11 Harefooah: Palestine's first medical journal. American Journal of Nursing, 1920, 20, 980.
12 Noyes, C. The Red Cross. American Journal of Nursing,^ 1919, 19, 2>ei-lb.
13 Selisberg, A. A modern training school for nurses in Jerusalem. American Journal of Nursing, 1921, 21, 721-3.
14 Shulamith, L. A nursing school in Palestine. American Journal of Nursing, 1940, 40, 880-4.
15 Weiss, 0. Kibbutz nurses. American Journal of Nursina^ 1971, 71, 1762-5.
16 Weiss, Q. Nurses and nursing in Israel. Nursing Outlook, 1966, 14, 58-60. CHAPTER 16
IRAN
In past centuries Persia, now known as Iran, had
Government hospitals in its chief cities that were staffed with paid attendants. Later, the fatalistic attitude of the
Moslem religion slackened the interest of the government which resulted in neglect of the sick. In the middle of the nineteenth century, however, American missionaries demon- strated great interest in the area and as a result began medical work by gradually establishing hospitals in several cities. Also, American and British church missionaries opened some schools of nursing, the oldest of which were at Tehran and Tabriz, started as early as 1916. In spite of the availability of schools of nursing, a lack of qualified applicants existed for a long time. Women were secluded and girls did not have sufficient education at the high school ,2:384 level.T
The Development of Modern Nursing
The abolition of the veil was ordered in January 1936 and women were encouraged to find themselves a career or a profession outside the home. This remarkable change opened an avenue for the development of modern nursing in Iran 241 242
As a result, three schools of nursing were opened in Tehran,
Tabriz, and Meshed. Since the Minister of Education was
familiar with nursing education in America, American nurses
were recruited to organize these schools. In 1937 the
Board of Foreign Missions of the Presbyterian Church asked
three nurse-educators to go to Iran in order to help organ-
ize the new schools of nursing. The course of study in
these government schools was two years; students admitted
had had nine years of general education. In order to
raise the prestige of nurses in the country, graduates of
these ^ = 5 ^ = 522 schools were called doctor's assis tants .
After World War II the Imperial Foundation under
the sponsorship of the Royal Family took the task of improv-
ing nursing conditions in Iran. As a result, the Princess
Ashraf School of Nursing was built and British nurses were appointed to teach in it. The admission requirement was eleven or twelve years of general education. To be more prestigious, the school of nursing affiliated with the
University of Tehran Medical School. This accomplishment
^ ' ^^^"^ pushed nursing education forward. Also, the estab- lishment of a nursing school by the Red-Lion-and-Sun Organ- ization, known as the Iranian Red Cross, was another evidence of the awakening interest in the profession. The teaching staff of this school was greatly assisted by the World ^' Health Organization nursing edcation department ' 243
Public Health Programs
Iran's generalized public health program was started
in 1951 under the direction of American nurses and the Amer-
ican Point Four Program. The foremost aim of such a program
was the training of public health nurses by means of a two-
year course which prepared them to instruct the villagers
on personal and community hygiene matters, nutrition, mater-
nal and child health and communicable diseases . The curric-
ulum of such programs included clinical and bedside nursing
care as well as theoretical work. The American nurses at
first took complete charge of nursing activities. In time,
however, as Iranian nurses gained more experience, more ^ "'" responsibilities were delegated to them. ' " In answer
to the severe shortage in nurses, midwives were recruited who, because of their good preparation, accomplished pioneer work in the public health field in Iran.^"^^
Nursing Division
In 1952 the Ministry of Health approved establishment of a nursing unit which later became the nursing division.
This recognition has helped Iranian nurses receive deserved recognition as a profession. The division consisted of four sections, each with its own consultant in the fields of public health, nursing education, hospital nursing service administration, and nursing resources and registration.
The division set standards defining the education of nurses 244
and the services of nurse educators. Assistance was also
given to school administrators in the development of their
policies, planning and implementing curricula, and in the
c o /• . Q q improvement of methods of testing and evaluation.
Nursing Education
Nurses from Iran attended the First Grand Nursing
Conference in 1956. It was planned following the recommen-
dation of the Ninth World Health Assembly that emphasized
that individual countries should review and evaluate their
nursing programs to improve the status of nursing and the
care of the sick. As a result of this conference, constitu-
tions for professional and practical nursing schools were
drafted and approved by the Council of Education in 1958,
This movement led to the raising of professional require-
ments for schools of nursing to the twelfth grade of general
education and to the extension of the program to cover three
calendar years. The requirement for practical nursing schools
was set at ninth grade of general education to enter a two-
year course ^ " ''^ of study . The Nemazee School of Nursing,
founded in 1954, was the first school in Iran to reqire the
minimum twelve years general education for its applicants.
It was also the first school to give the certificate of ^"'^ "License" ' in English to its graduates .
The first school to offer the four-year course in nursing leading to the Bachelor of Nursing Science degree was established in 1965 by the World Health Organization. .
245
Other schools were later established which included in their curriculum general college courses as well as nursing courses. As part of an overall plan for the development of advanced nursing education, this program provided an oppor- tunity for registered nurses interested in teaching and supervision positions to seek a bachelor's degree in nursing.
The medium of instruction is English and the program usually requires five semesters. The creation of this university- level postbasic program has opened the possibility for nursing to develop in harmony with other sciences in the area.3^^08-9;4:5-6;5:270
Preparation beyond the basic nursing programs in
Iran became available for the first time in 1954 as mid- wifery training. Prior to that time a midwife was not required to be a nurse. The basic midwifery course earlier was offered by the University of Tehran over a three-year period. However this training course was changed to a twelve-month postbasic program in 1954 and is still offered at the University of Tehran to graduate nurses. Scholar- ships were also made available to graduate nurses inter- ested in seeking graduate education in foreign countries.
Many nurses went to Lebanon seeking either the bachelor's degree in nursing or the master's degree in public health both of which are offered at the American University of
Beirut. Other nurses were sent to England or to the United
States for further study or specialization in nursing areas 5:270-l;7 246
The Iranian Health Corps
The shortage of trained health personnel exists in
most countries of the world and especially in the underdevel-
oped and developing countries. To provide health care
facilities to the rural areas which constitute 60 percent of
the population, the Iranian Government established the Iranian
Health Corps into which most medical graduates and some high
school graduates are inducted instead of the regular military
service. However, this program has not been able to expand
into a comprehensive health care system because many of these
physicians and their assistants after the two-year draft
period choose to practice in urban rather than rural areas.
To remedy this problem, the primary level health worker was
introduced into the health system. Trainee candidates ad- mitted into the programs should have six years of general
schooling, should be no less than eighteen years of age, and
should be inhabitants of the areas where they are to serve.
The curricula of these programs are designed in accordance with ''^"^ ' ^ the needs of the rural areas and are six months long. ^
This project, derived from observing the functions of the Chinese Barefoot Doctor, is planned to follow such models in different countries in which village authorities participate in the selection of candidates to be trained as auxiliary health workers. These workers would live and work in their own villages. On graduation from the program the health workers spend from one to six hours per day in a clinic ^
247
During which time they see and treat patients, sometimes
referring them to the Health Corps Station Physician.
Patients are also instructed on preventive measures to
obviate a return visit. Through the home and village visits
for the purpose of followup care, the workers discuss with
villagers either idividually or in groups, family planning,
sanitation, and nutrition matters. A full-time physician is
responsible for the work done at the clinic and usually checks
^ ^ ' on the health workers at least once a week .
Iran, like other developing countries, is faced with
difficulties in its attempts to establish an effective health
care delivery system. Easing the manpower shortage seems to be the most critical step at present in providing better health care for the people. 248
References
1 Aftab, S. Nursing and Point Four in Iran. Nursing World, 1953, 127, 8-10.
2 Goodnow, M. Nursing history (9th ed.). Philadelphia: W.B. Saunders, 1955.
3 Kelly, M.A. Beliefs of Iranian nurses and nursing stu- dents about nurses and nursing education. International Nursing Review, 1913, 20, 108-11.
4 Moghadassy, M. Progress: Postbasic nursing education in Iran. International Nursing Review, 1912, 19, 3-11.
5 Riahi, A. Nursing education in Iran. International Journal of Nursing Studies, 1968, 5, 267-71.
6 Ronaghy, H.A. The front line health worker: selection, training, and performance. American Journal of Public Health, 1916, 66(3), 273-7.
7 Ronaghy, H.H. Migration of Iranian nurses to the United States. A study of one school of nursing in Iran. International Nursing Review, 1975, 22(2), 87-8.
8 Salsali, A. Iran's nurses. American Journal of Nursing, 1961, 61, 99.
9 Setzler, L. In Iran. American Journal of Nursing, 1941, 41, 520-5. CHAPTER 17
INDIA
India's fatalistic religions, Hinduism and Moslemism, hampered the progress of nursing in that country for a long condi- time for they discouraged interference with existing tions. Also, the low status of women, the seclusion of
Moslem women, racial prejudice, general illiteracy, and poverty played a part in halting attempts for the develop- ment of a good health care system.^ Before the Western powers in general and the English in particular established rule in India, Christian missionaries did the first skilled nursing in India, establishing hospitals to provide medical
relief. During the latter part of the nineteenth century, missionary nurses who came to India from England, Australia,
France and America worked hard to establish missionary
centers which in many cases served as health clinics for l:224;10:371-2 treating and teaching the public.ui-
The Lady Dufferin Fund, established in 1885 and now
administered by the government, began by educating women
physcians and was extended later to nurses. Earlier,
foreign women physicians and nurses cared for the women
patients who were not allowed to be examined by male
249 6
250
doctors. The establishment of the British rule, as a result,
gave impetus to the establishment of the medical services
which were '"^ patterned after those of European countries .
Other Western powers, such as France and Portugal, also
influenced nursing and medical practices in India. The
influences of these countries were merged with the tradi-
tional beliefs and practices of the natives of India which
led to health services patterned after those of the various countries. ^=224-5;
The first two nursing schools were established at
Madras and Bombay in 1884 and 1886 respectively. During
the same period, a number of missionary hospitals organ-
ized short nursing courses. Soon, schools of nursing
patterned on the lines of the Western countries were estab-
lished throughout the country and nursing education grew
from that offered in the three cities of Calcutta, Madras, and Bombay which formed the bases of administration of the
British rule. From that time on, a gradual extension of modern nursing in India took place, in spite of the fact
that difficulties of religious and racial customs, and political conditions had been greater there than in any
'-^ • -^^^"-^ other part of the world. '
Nursing Developments
The year 1943 marked the awakening that had tremen- dous influence on the practice of nursing in India. With World War II at its height and with freedom within sight, 251
the realization came that the departure of the British nurses
would have tremendous consequences on nursing administration.
British nurses at the time constituted most of the nursing
teachers and matrons of the country. The Indian Military
Nursing Service, realizing the realities of the situation,
persuaded the government to make provisions for the prepara-
tion of Indian nurses for administration and teaching posts.
This movement provided enough impetus among government offi-
cials that the first pos tcertificate School of Administration
was started in Delhi. Gradually the idea caught on. The
Civil Nursing Services took advantage of the situation and
instituted a course for nurses interested in teaching.
Scholarships for both courses were made available through
government agencies, the Indian Red Cross, and the Minto
^ ' Nursing Association .
The Shore Report
The appointment of the Health Survey and Development
Committee was another highlight of the year 1943. This
committee was given the task of surveying the health ser- vices of India and recommending the development of programs 8 5 0 in • the field. The report of the committee known as the
Bhore Report, was published in 1946. It was a blueprint of the health needs of the people, recommending ways and means of meeting the overwhelming magnitude of health problems existing then. Of nursing, the report described the 252
conditions as deplorable and stressed the importance of
having educated Indian women join the profession to raise
its Standards. '
The establishment of the two baccalaureate programs
in nursing at the College of Nursing in Delhi, and at the
School of Nursing in Lahore were direct outcomes of the
Bhore Report. The course proved to be valuable in encour-
aging a group of educated women to join the profession in
spite of family resistance that viewed nursing as the job
'' of the low caste. = -^^^'20:273 xhese programs integrated
academic work and nursing courses throughout a carefully
planned four-year program.
Male nurses played an important role in the health
care programs of India. This is attributed to the social
conditions and customs of the country which give men more
freedom than women. As a result, men could go out to nurse
in districts where women were not allowed to tread. Another
outcome of the Bhore Report was the recruitment and training of male nurses so that they could be employed to a greater extent in male wards and male outpatient clinics of govern- ment hospitals. "'•^^^"^
The Indian Nursing Council
The Indian Nursing Council Act of 1947 was the predecessor for the National Nursing Council, established in 1959 as a result of the recommendation of the Bhore Com- mittee. The main purpose behind the National Council was ^
253
to bring about uniformity in nursing education
The first five-year plan, started in 1950, emphasized the
development of public health services and hence the train-
ing of personnel to serve in the different areas. The World
Health Organization and UNICEF provided advisors as well as
equipment and personnel to help start such a nationwide
campaign. Soon Indian and international teams were working
side by side to combat the spread of infectious diseases
which "^"^"^ were prevalent in the postwar period. ' In the
meantime, many one-year courses were made available in pedi-
atrics, tuberculosis, public health, and psychiatric nursing
for graduate nurses immediately involved in these areas "
Primary Health Care
In 1952 the integration of medical and public health
services at all levels and the establishment of primary
health centers were launched by the government. These cen-
ters catered for both preventive and curative services by
providing personal and informal care to the rural population.
Health education, antenatal and postnatal care, family plan-
ning, child health care, and home visits comprised most of
the activities of "'"'^ '•^•^"^ primary health centers . ' Also, the
Red Cross society of India, having the cooperation of the
upper classes, sponsored two-year training courses for health visitors, including midwifery. Graduates of these courses worked in rural areas teaching and promoting health care
' "'"^ ' ^''"^ among Indian people . ' 254
Nursing Education
As in the case of basic education, India had also an
early start in postcertificate education. Courses that are
presently available include ward administration, pediatric
nursing, midwifery, nursing education and nursing school
administration. All students are required to take the three-
month ward administration course which is followed by seven
months in any one of the other areas. However, a revision
of the program leading to the nurse- tutor degree is indi-
cated. It will include more emphasis on science and nursing.
There is a trend as well to integrate these courses into the
baccalaureate program and provide specialization at the
^ ^^"^"^ ' -"-^ '^^"^ masters level . " A postcertificate course in
public health nursing was added as a result of emphasis by
the government on the expansion of health services in the
country. Many courses were developed in this area that
gained international importance, bringing in candidates from
the Southeast Asia region.
As mentioned earlier, university education in nursing
in India started as early as 1946. The colleges offer a
four-year program leading to the Bachelor of Science degree
(Honours) in Nursing and qualifying students in general nursing, public health nursing, and midwifery .''"^ Although the curriculum is modeled after the American system, some adap- tation to the conditions in India focus on the curative and preventive aspects of nursing, and to a greater extent on 255
family planning, which constitutes a major national objec-
tive in the health care delivery system of India. All grad-
uates of the baccalaureate programs are exempted from the
government's final examination for the university's examin-
"^'^ ^'^ '•^'^"^ ' ations are honored for registration and licensure '
Postgraduate education in nursing is relatively new
in India. For many years, nurses were sent abroad for study
on the advanced level. The first masters program in nursing
was established in 1959 at the University of Delhi. Another
program was established ten years later in South India at
the College of Nursing in Vellore, which is affiliated to the
University of Madras. The general aim of these and other
programs is the development of advanced competence in profes-
sional nursing with emphasis on specialization in a major
clinical area, as well as on teaching and administration.
Field experiences in the three areas is provided with special
attention to teaching in the clinical areas. An innovation
in the graduate program is the introduction of a course on
international health and nursing with the main purpose of
developing further understanding of international health and nursing activities, particularly the administration and organ-
^ '"'^ ^^^"^ ization of programs at the international level . ' ' '
A course for auxiliary nurse midwives is available
also to prepare candidates to staff the rural health centers.
This two-year course includes nine months of general nursing,
and fifteen months of midwifery. Upon completion of the 256
course, graduates work as midwives in primary health centers.
Auxiliary nurse-midwives can take general nursing with six
months exemption from the total length of study, a provision
made possible by the Indian Nursing Council '^'^"'^ Follow-
ing the tradition of England, the health visitors' course
was established by the Indian government. A two-and-a-half-
year program, it prepares candidates for the Health Visitor
Certificate. Graduates are employed in maternity and child
health clinics to supervise the work of auxiliary nurse
midwives. Health visitors can have an overall one-year
exemption if they decide to take general nursing, on the
condition that they meet the entrance requirements. Both
auxiliary nurse midwives and health visitors are increas-
ingly utilized in India in family planning work, a role con- sidered to be of prime importance for the Indian national ^•^^"^'^^'•'^ health program.
Nursing Associations
The official nursing associations in India are similar to those of the English-speaking countries. The two recog- nized nursing organizations are the Trained Nurses Associa- tion of India and the Association of Nursing Superinten-
, ^ 10:375-6 „ . . cients. Nursing registration began in 1923 as a result of efforts by the Trained Nurses' Association. The same association edits the Indian Journal of Nursing, which compares favorably with some of the nursing journals in the 257
world. With the work of the organizations and the enthusiasm
of the nurses, India has accomplished important developments
in its nursing world.
Public Health Nursing
The impetus to the development of public health
nursing has started with the development of the community
health programs and primary health centers. In addition,
the Bhore committee saw that the v/ork done by the health
visitors was not sufficient to meet the needs of the
country and to reach all sections of the population.
At least four categories of staff presently comprise the
public health team in India:
(1) the public health nurse who has had a post- certificate course in public health nursing or a Bachelor of Science degree in nursing recog- nized by the Indian Nursing Council,
(2) the nurse who has had a short course in public health nursing or has had public health inte- grated in the basic course,
(3) the health visitor, and
(4) the auxiliary nurse-midwife.
Supervision of the nursing staff in the public health field is done by health nursing supervisors who are assigned to every district in the country . ''"^ •
International Aid
International agencies have contributed considerably to the advancement of nursing in India during the last ten 258
years. Aid in the form of fellowships and stipends, teaching and hospital equipment, and nursing teachers were provided by the different agencies. Fellowships for study abroad have given nurses the opportunity to specialize in a partic- ular field of study or to qualify as teachers or administra- tors. Stipends made available by UNICEF have enabled a num- ber of midwives and public health nurses to join the profes- sion and have given the courses a good start by assuring a steady flow of students. The aid received from UNICEF was used in planning refresher courses which made it possible to bring nurses together from all parts of the country and to update them on their particular field of nursing. This has also provided a means in planning curricula in line with revised syllabi and in developing a more uniform pattern of
' nursing education .
In addition, UNICEF has supplied India with teaching equipment and supplies to schools of nursing which have contributed to the improvement in the teaching programs.
Also equipment provided to hospitals, health centers and clinics has helped in raising the morale of health workers by giving them good tools with which to work
The most valuable of all the work given to India by international agencies has been the contribution of the international nurses. Nurses from the World Health Organ- ization have helped in various projects such as malaria, tuberculosis, venereal diseases, maternal and child health. .
259
mental health, nursing administration and nursing education.
Also nurses assigned through the United States Agency for
International Development have helped to develop nursing
at the state and central levels by establishing collegiate
courses in nursing. Nurses under the Colombo Plan have also
had their share in developing college- level teaching pro- 11: grams 11
Nursing Service
Indian nurses are presently working in all branches
of the health care delivery system such as hospitals, health
centers, sanatoria, industry, control programs for communi-
cable diseases, and also in private schools and schools for nurses. Some 95 percent of all nurses and midwives are
employed by hospitals and nursing schools, whereas almost
all health visitors and auxiliary nurse-midwives are employed by maternal and child health clinics and primary health
centers. This trend is changing, for all nurses will be
required to work in primary health centers when they are
11 • 1 2 called upon to do so. )
260
References
1 Ahad, M.A. Nursing education in India. International Nursing Review, 1970, 17, 224-37.
2 Baehu, A. The nurses role in family planning services in India. International Nursing Review, 1976, 23(1), 25-8.
3 Baehu, H. Indian nurses in I.S.A. International Nursing Review, 1973, 20, 114-6.
4 Baehu, M. Problems of nursing education in India in an age of technology. International Nursing Review, 1911, 18, 85-95.
5 Bauman, M.B. Baccalaureate nursing in a selected number of English speaking countries. International Nursing Review, 1972, 9, 12-38.
6 Burnett, D. A nurse visitor in India. Public Health Nursing, 1951, 43, 408-12.
7 Devi, I. Programs for India's graduate nurses.
American Journal of Nursing , 1956, S6, 334.
8 Devi, L. Twelve years of nursing in India. Inter- national Nursing Review, 1955, 2, 49-52.
9 Dock, L. India. American Journal of Nursing, 1903, 4, 240-4.
10 Goodnow, M. Nursing history (9th ed.). Philadelphia: W.B. Saunders, 1955.
11 Information Service of India. Note on the history and development of the nursing services in India, 1977. Unpublished manuscript. (Available from the Informa- tion Service of India, Embassy of India, Washington, D.C.
12 Information Service of India. Nursing profession in India, 1953. Unpublished manuscript. (Available from the Information Service of India, Embassy of India, Washington, D.C.)
13 John, K. The advent of integrated health services in India. International Journal of Nursing Studies, 1965, 2, 183-7.. 261
14 Krishnan, S. Planning nursing education for the 70s in India. International Nursing Review, 1971, 18, 181-91.
15 Libbey, A. Junior year in India. American Journal of Nursing, 1966, 66, 332-4.
16 Macry, H. Nursing in India. Hospital Progress, 1941, 22, 283-7.
17 Marson, W. India's project number one. Canadian Nurse, 1967, 63, 45-9.
18 Paul, E.H. Nursing program of the Indian Red Cross Society, International Journal of Nursing Studies, 1967, 4, 56-62.
19 Pe, A. Hope for millions. Nursing Times, 1965, 61, 1494-5.
20 Saunby, D. A candle lighting service in Kolar, India. American Journal of Nursing, 1946, 46, 873-4.
21 Subhadra, V. An evaluation of public health services at an urban health center. International Journal of Nursing Studies, 1970, 7, 257-65. 8
CHAPTER 18
JAPAN
The development of modern nursing in Japan has a
different history. After the opening up of Japan to
foreigners about 1853, German physicians drew many Japan- ese students to Germany and the Japanese Government also imported many German teachers to help in establishing hospitals and schools. The first hospital was built by the
Government in 1857 and put in charge of a Dutch physi- 5 3 6 7- cian. It is not surprising then, that the early beginning and the development of nursing in Japan was derived from the same system of German hospitals, and espe-
^'^^ cially ' the German Red Cross system of training nurses .
The Development of Modern Nursing
Under the auspices of the American Board of Missions,
Dr. John Berry in 1885 established the first school of nursing for Japanese women, with Linda Richards in charge '^'"^ . Three married women and two others were the first students. Miss Richards remained in charge for five years but eventually the school passed into Japanese hands. Shortly after, another school was opened in Tokyo
Charity Hospital by Dr. Takagi, a Japanese physician who
• 262 263
studied in London and consequently wanted with the encour-
agement and approval of the Royal family to introduce the ^"^^"^ Nightingale system. ' In 1890 the Red Cross estab-
lished a school of nursing in the Central Red Cross Hos-
6 2 72 " pital in Tokyo , Ladies of nobility and of Royal
ancestry were encouraged to take the two-year course and
thus to qualify as nurses. This was the Motherhouse system
of Red Cross schools and hospitals which was highly central-
^ = 224-5 ; : ized and militarized. 4 209 ; 8 : 419
Another major development in nursing was the estab-
lishment of the great St. Luke's International Medical
Center in Tokyo. This was accomplished through the combined efforts of the Protestant Episcopal Churches of America and
the Japanese Government. In connection with the center, a school of nursing was founded in 1904 which later became
the official college of nursing. The newly founded college had a three-year basic nursing course, followed by a year of postbasic education in teaching, supervision, and public health nursing. This four-year course that trained nurses for leadership positions was based on the curriculum organ- ized by the National League of Nursing Education ''^ •
In 1928, the college of nursing was the first to be recog- nized and chartered by the Department of Education "'"^'^'^"^
The National Nurses Association
Between 1917 and 1947, the educational requirement for admission to a nursing school v/as six years of elementary 264
education plus two years of junior high school. During this
period, graduates from the nursing schools earned certifi-
cates as nurses, midwives , or public health nurses. In 1948
the Public Health Nurse Midwife and Nurse Law was passed by
the Ministry of Health and Welfare. It prescribed the qual-
ifications, training, practice, registration requirements,
and national examinations for both graduate nurses and
13 • 35 assistant nurses. " At about the same time, the national
nurses association, known as the Japanese Midwives, Clinical
Nurses, and Public Health Nurses' Association, was regis-
tered by the Japanese Government with the aim of promoting
. ''"^ ^''^ professional and general education " As a result, the
Red Cross Demonstration School of Nursing was opened in
Tokyo, to become a center for refresher courses for nurse
administrators, nurse educators, and clinical nursing
• specialists. 8 ' 419
Nursing Education
As a result, education of nurses changed with the
changing qualifications and educators came to realize that
registered nurses must be able to understand how to deal with the needs of the people and patients with knowledge
and technique of the advanced medicine, hygiene, psychol- ^'^^ ogy, and sociology of modern times. Under the 1948
law, the length of education of nurses is three years
following graduation from high school or 12 years of gen- eral education. To be eligible for the national 265
examinations for midwives or public health nurses, candi- dates must have more than six months of training in the respective areas in addition to their basic nursing 9:157 education of^ three years.
Also, with the enactment of the 1948 law, the assistant nurse — a new category of nursing personnel —was created. The assistant nurse under the law should practice nursing under the supervision of a doctor, a dentist, or a registered nurse. The length of training of the assis- tant nurse is two years following graduation from junior high school or nine years of general education. In 1951 provisions were made for an assistant nurse licensing sys- tem which permits licensing by the prefectural governor after completion of the two-year program and passing the examination.. ^.15:75
In order to meet the increasing demands of the popu- lation the government established a policy giving priority to quantity over quality of nursing personnel, strongly affecting the overall direction of nursing education.
As a result, a large number of schools for assistant nurses have been established, presently exceeding the num- ber of the schools for fully qualified nurses. More schools are also being established that offer programs for assis- tant nurses, with more than three years of clinical expe- rience, to make them eligible for the national examination for fully qualified nurses. A night course is made available 2
which was approved by the government for the training of
assistant nurses. In 1964, another program was introduced
by the Ministry of Education which involves a three-year
course for assistant nurses at the high school level that
offers vocational training. Graduates of this program are
allowed to enter the training program for assistant nurses
to become fully registered nurses and hence obtain their
nursing licensure. This makes the education system in
Japan rather complicated and as a consequence, many dif-
ferent ways to obtain a nurse ' s license are available for
students interested "'•^ " ^^"^ in participating in nursing .
(See Figure 5.)
Following the development of comprehensive medical
care, which was officiated in 1963, the government made an
overall revision of the curricula of nursing education in
1969. The new curriculum was organized to prepare nurses who are able to provide comprehensive nursing care rather than to train the students mainly for clinical work in hospitals and clinics. The education of nurses under the new curriculum involves caring for patients or clients with due consideration to their daily life and their community living. 77
Advanced Nursing University Education
Baccalaureate-level programs were first developed in 1952. By 1975 ten university programs offered a nursing degree. Postbasic courses for nurse- tutors are offered by )
267
National Examinations
for for Midwife Public Health Nurses (Midwives' License) (PHN License)
National Combined School School Examination Course for of for (Nurses RHN & Midwife Midwifery PHN License) (6 mo. or more) (1 yr.) (6 mo. or more) or or
Nursing Additional Junior Nursing Junior University School 2-yr. College School College Baccalaureate (2-yr. Programme of Nursing (3 yrs.) 5f Programme Day in (2 yrs.) Nursing Nursing in Course) High School (3yrs.) (3 yrs.) Nursing (3-yr. Nursing (4 yrs.) Night Course Course)
Examination for Assistant Nurse (Prefectural (Assistant Nurse's License)
Assistant Nurse High School High School Training School Nursing Course (3 yrs.) (2 yrs.) (3 yrs.
Compulsory Education ; (9 years) (6 years in elementary, 3 years in secondary)
Figure 5. Nursing Education in Japan.
Adapted from: Tokyo Planning Committee. ICN 16th Quadrennial Congress Nursing education in Japan. International Nursing Eevvew, 1976^ 2Z(s), 73-9. .
268
the national local governments, and also by the Japanese
Nursing Association. These courses are 6 to 12 months
long. Other short-term courses in nursing administration
"'"^ " are also available . ^ Graduate education at the masters level is not available yet, but efforts are being made to institute these courses in the near future
Public Health Services
General public health services in Japan are provided at three levels: national, prefectural, and local govern- ment. Each prefectural government and local large municipal government has its own health department to carry out programs that are in general directed by the Ministry of
Health and Welfare. National Health Insurance, which is compulsory for all residents, was established in 1938.
In 1958 every city, town, and village was given the respon- sibility of enforcing the National Health Scheme, and conse- quently a comprehensive insurance system for the entire
"^^ ' ''"^"^ nation was achieved by 1961 . The Japanese primary care and emergency systems which cover the entire population have strengthened the national health program in making it available to every Japanese person in need of health 9: 158 care
Among the problems Japan faces in the health field is the shortage of health facilities and manpower, includ- ing doctors and nurses.'^ Also, the fact that the typical 269
nursing school or training institute is still of diploma
level, in general sponsored by a private hospital, is a problem nursing education faces at present. Since most of
the nursing is done by assistant nurses, a considerable
effort is being put into upgrading these programs, which are
still dependent on medical associations. In addition, the
country lacks continuing education programs for nurses who have been working for some time in clinical areas.
Currently the Japanese Nurses Association is working on resolving these problems and on reforming the nursing edu-
cation system thus placing all nursing programs within the
frame of higher education. 270
References
1 Arak, I. Nursing in Japan. Americayi Journal of Nursing^ 1928, 28, 1003-6.
2 Bullough, V. and Bullough, B. The emergence of modern nursing (2nd ed,), London: The Macmillan Co., 1969.
3 Chino, L. Nursing in Japan. International Nursing Review, 1964, 11, 19+.
4 Dock, L. and Stewart, I. A short history of nursing. New York: G.P. Putnam's Sons, 1938.
5 Goodnow, M. Nursing history (9th ed.). Philadelphia: W.B. Saunders, 1955.
6 Hayashi, S. L' influence de Florence Nightingale sur le development des soins infirmiferes au Japon. Revue International de la Croix-Rouge , 1954, 3B , 272-8, (French)
7 Iwasaki, H. James Bond's nurse. American Journal of Nursing, 1968, 68, 94-5.
8 Jameison, E., Sewall, M. and Suhrie, E. Trends in nursing history (6th ed.). Philadelphia: W.B. Saunders, 1966.
9 Japan: Health care for all and a demographic miracle. Hospital Practice, 1976, 11, 157-8.
10 Jensen, D.M. History and trends in professional nursing. St. Louis: C.V. Mosby, 1955.
11 Kaneko, M. A new aim of nursing education in Japan. International Journal of Nursing Studies, 1969, 6, 141-9.
12 Kusakari, J. Fact about public health nursing in Japan.
. . . Changes during the years 1960-1970. International Journal of Nursing Studies, 1974, 11, 3-19.
13 Nagano, S. Nursing in Japan. Canadian Nurse, 1974,- 65, 35-6.
14 Richards, L. Linda Richards in Japan. American Journal of Nursing, 1968, 68, 1716-9.
15 Tokyo Planning Committee, ICN 16th Quadrennial Congress. Nursing education in Japan. International Nursing Review, 1976, 23(3), 73-9. CHAPTER 19
CHINA
No record in Chinese history before the nineteenth
century exists through which one can trace the words nurse
or nursing. In the past the care of the sick was mainly
done by relatives and servants. Women in general were not
educated and those who could afford it were taught by private
tutors. The teaching then involved the study of Confucius'
classics and the education of young girls to be obedient 12-1-2 to their parents and husbands . ' Around the middle of
the nineteenth century, nursing care was provided entirely
by a servant type of nurse who v/as trained to do some manual
work while medicine and treatment were entirely in the hands ^-^^^'^^-^"^ of the physician.
The Beginning of Modem Nursing
The first hospital was established in 1835 by
Dr. Peter Parker of Canton, a distinguished missionary
physician. Other mission hospitals were founded, but
history records no attempt of their training nurses. The
first graduate nurse to work in China was Elizabeth
McKechnie Thompson from the United States who went to
Shanghai in 1884 to plant the first Nightingale system
271 5
272
of nursing. Other British and Australian nurses trained
under the same system also contributed to the establish-
• ^^^"^ ' ^ ' : ment of modern nursing in China.^ '
With the turn of the century, education of Chinese women began and brought with it the dissolution of old
customs such as the foot-binding of baby girls, and the belief that women's place is only at home. Soon efforts were made to train Chinese women to become nurses. Male nurses were also trained for it was thought improper for a women to nurse a man who was not her husband— a belief
"^^^ ' ^^'^ ^ • that is presently waning . "
The first school for Chinese nurses was started by
Ella Johnson in 1890 in a small mission hospital in Foochow,
Practical nursing, midwifery, and dispensing were taught at the convenience of the teachers in a course which lasted two years. Other schools were opened but none emphasized _ the educational background of the student. This opened the doors to the servant-type of nurse since educated women were not yet willing to take up this task which was not
. • highly esteemed by the public ' ^ '
Nursing Developments
During the Russo-Japanese War in 1904, the Chinese
Red Cross Society was established by Chinese residents in
Shanghai. This was followed by the opening of a Red Cross
Hospital in 1907 and a Red Cross School of Nursing in 1921.
The Nurses' Association of China (NAC) was founded in 1909 273
by Cora Simpson with the main purpose of establishing
standards for nursing education and regulations regarding
national examinations. By 1912, a standard curriculum was
established and a central committee was empowered to
accredit schools. In 1915, the first examination for nurses
was administered by the Nurses' Association of China and in
1920 the first issue of the Nursing Journal of China was
published. The Nurses' Association of China joined the
International Council of Nurses in 1922 and has been an
active member ever since '^'''^
Many prominent schools were established in the same
period, most of them under government auspices. The most
notable one was the Nursing School of Peiping Union Medical
College which required senior middle school graduation but
preferred college education. A combined university and
nursing course was offered in affiliation with Yenching
University. Graduates from this program held leadership
positions in many parts of China and some of them became
leaders in hospitals and schools of nursing in the country.
While modem nursing and modern medicine were introduced
into a number of cities in China, large territories of this
country for a long time remained untouched and untreaded by these professions. 12 • 7 8
Public health nursing with all its possibilities
for the elevation of living standards was inaugurated at
Peiping Union Medical College in 1925. The students of the 274
school of nursing of the college, and students from other
hospitals in Peking, affiliated with this program. Gertrude
Hosmer organized the first public health nursing program in
China. It was comprised of a nine-month postgraduate course,
offered to graduates from the various Chinese schools of
nursing. The Chinese Government gradually developed this
program by opening national schools of nursing throughout
the country and making available scholarships to graduate
nurses interested in working in public health . ''"'^ ' '^'^^
Government involvement in the nursing profession was con-
tinuously increasing and in 1937 the education of nurses
was placed under the Ministry of Education. This change
helped in setting standards for registration of schools of
'^^^ ' nursing as well as licensure of graduate nurses .
Health Care in Communist China
During the eight long years of war, from 1937 to
1945, hospitals were established everywhere in China— in
temples, factories, storehouses, mills, and schools — to
compensate for the lack of transportation facilities.
Nurses worked under impossible conditions in meeting the war needs and in training aides and corpsmen. An army
school of nursing was established in 1943, and nurses were
given military rank. Help came to China from international
organizations such as the Red Cross and the United Nations.
Nursing activities during that period were hampered first by
the war with Japan and later by the Chinese Communist regime, 275
which reduced the educational standards of nursing by reduc- 8:362-3;ll:478-9 mg the program to. two. years ofP training..
Most of the nursing schools were closed for the foreign nurses, and the missionaries in charge of them were labeled by the new government as agents of Imperialism and hence
2 • 220 were expelled from the country.
Since 1949, the year of the "liberation," the
Chinese Communist government has made determined efforts to improve the health of the people by mass eradication of communicable and endemic diseases through the elimination of health conditions that lead to these diseases and by
proper education of the public on health issues , This was made possible because the improvement of health care has been put into practice by every segment of the medical com- munity, including educational institutions, health facilities, and health practitioners at all levels. Emphasis all along has been placed on the countryside where the majority of the people live and where the medical facilities were the least l:405-6;4;9 available•1 ui beforeu ^= 1949.10/Q
Health Education
Health education is widespread throughout China now and medical training is available to all at all ages.
Villages and factories are supplied by health workers known as barefoot doctors who are commonly recruited from the area.
Courses in health training are also available to every segment 276
of the population allowing graduates of one course to move
easily to another. Many people in China learn a few basic
acupuncture points and, hence, proceed to practice on them-
selves to perfect the technique which allows them later to
become acupuncturists. The technique usually involves plac-
ing one or more needles in certain sites of the body and
1-5 * 2 A-3 rotating them until analgesia is induced.
Health education in general mixes theory with practice,
Even school children of all ages spend a part of their aca-
demic year putting classroom theory into practice. Prospec-
tive nursing students in China are required to spend a period
of time in the hospital as patient attendants and housekeepers
. "^^^ before they enter a school nursing ' ^' of Housewives ,
farmers, middle-school graduates, and factory workers are
chosen by the community to study three or four months each
year in their own local hospitals or health centers to
become barefoot doctors and sanitarians and at the same time
they are apprentices to doctors, nurses, midwives, acupunc-
turists, and dentists .''^ The barefoot doctors, after several
years of part-time education and training, may be chosen to
continue their education to be qualified to enter one of the
"7 1 • 9 9 1 / other categories of health workers.
Nurses, midwives, acupuncturists, physicians,
herbalists, sanitarians, barefoot doctors, anesthetists,
laboratory technicians, dentists, pharmacists, family plan- ning workers, medical and nursing students comprise the 277
13 health workers categories. This provides for the existence
of different levels of health workers but at the same time
allows for easy mobility from one level to the other. The
beginners are usually people from neighborhoods or class-
rooms who are known as contact persons and who take the
responsibility of checking to see that people in their area
are receiving the proper medical care.
Since the Great Proliteriat Cultural Revolution, the
Peking Medical College has run an open-door schooling system
by linking . its educational revolution with the revolution in
rural health work. Teachers and students of the college,
led by the College Party Committee, did their best to reduce
the shortage of doctors and nurses in rural areas , Courses
were chosen to fit the needs of the rural areas and hence
enable students to. become professionals with a mastery of
both Chinese traditional medicine and Western medicine,
prevention and treatment of diseases, collection of medicinal
• ^ = = herbs, and preparation of drugs . ^
In order to raise the socialist consciousness and
medical skills of the practicing barefoot doctors, a barefoot
doctor college was established by the Nantug Medical College.
Upon completion of the course students in the two-year
program are required to return to the brigades they came from
and continue to work as barefoot doctors. Courses include
lectures by physicians and political leaders of the commu-
nity who coach students in their study, of works by Marx,
Lenin and Chairman Mao . ''"^ ' '^^'^ 278
The Health Care System
To understand the Chinese health care system, one
has to be familiar with the writings of Chairman Mao that
provide the philosophical underpinnings of the whole system.
Mao's concern x^7hich had always been of the masses, is mainly
reflected in the orientation of the health care providers.
Mao placed the major emphasis of medical and health care on
the rural areas, a not surprising fact since 80 percent of
China's population live in rural areas. Figure 6 will help
the reader understand the levels of health facilities as
described by Chairman Mao. A Co-op Medical Care Plan at the
brigade level ensures 100 percent medical enrollment of the
population for a monthly premium of about 20 Fen, the equiv- ^^-^^^"2 alent of 10 U.S. cents.
Contrary to the widely held belief that the Chinese
system is a fully subsidized service from the government, a fee-for-service is the usual modality of payment within
the curative services in China. This is mainly due to the fact that the government has delegated the operational responsibilities to the locality and region which should be self-supporting and independent. 279
Central Government
21 Provinces (and 5 Autonomous Regions)
Commune Primary Hospitals , Street and (10,000-60,000) /V Lane /\ - (25,000-60,000)
Brigade Health Red / Residential (800-3,000) Station. Iledicine Committee Barefoot Guard. (500-2,000) Doctors Prevention and Treatment
Production Sanitation Workers Team "(100-300)
Figure 6. Levels of Health Facilities in China.
Adapted from: Wen, CP. Health care financing in China. Medical Cave, 1976^ 14(5), 241-54. 280
References
1 Branch, M. A black American nurse visits the People's Republic of China. Nursing Forum, 1913, 12, 402-11.
2 Bullough, V. and Bullough, B. The emergence of modern nursing (2nd ed.). London: Macmillan Co., 1969.
3 Chung, H.H. An exploratory study of clinical nursing activities as a preliminary step for planning changes in care delivery system. International Nursing Review, 1971, 18, 291-314.
4 Clawson, D.L. When the green and the yellow do not meet. American Journal of Nursing, 1971, 71, 1971-3.
5 Deepening the revolution in medical education. Chinese Medical Journal, 1976, 2(2), 87-92.
6 Dock, L. and Stewart, I. A short history of nursing. New York: CP. Putnam's Sons, 1938.
7 Gage, N. Stages of nursing in China. American Journal of Nursing, 1919, 20, 115-21.
8 Goodnow, M. Nursing history (9th ed.). Philadelphia: W.B. Saunders, 1955.
9 Gray, J. East meets West in Canton. Nursing Mirror, 1976, 142(3), 67-8.
10 Jameison, E., Sewall, M. and Suhrie, E. Trends in nursing history (6th ed.). Philadelphia: W.B. Saunders, 1966.
11 Jensen, D.M. History and trends in professional nursing. St. Louis: C.V. Mosby, 1955.
12 Lin, E. Nursing in China. American Journal of Nursing, 1938, Z8, 1-8.
13 Neonatal nurse practitioners. British Medical Journal, 1975, 1(5950), 115-6.
14 Pearson, S. A peep behind the bamboo curtain. Health services in China. Nursing Times, 1972, 69, 243-4.
15 Revolution in health and education. Chinese Medical Journal, 1976, 2(2), 149-54. 281
16 Stanley, M. China: then and now. American Journal of Nursing, 1972, 72, 2213-8.
17 Wang, R.M. China town in the classroom. American Journal of Nursing, 1974, 74, 113-4.
18 Wen, CP. Health care financing in China. Medical Care, 1976, 14(Z), 241-54. CHAPTER 20
TAIWAN
Formosa or Taiwan, as it is known to the Chinese,
is an island 85 miles off the Southern coast of China, with
^''"^ ^ ' a predominantly Chinese population . During the period
of Japanese occupation from 1896 to 1945, health facilities
and nursing schools were limited and those available were
managed by physicians. Existing hospitals resembled hotels
in which family members were allowed to stay with their
' ''"^^ patients and to cook their food at the bedside . Atti-
tudes toward health care were inherited from the Chinese
traditions and the Japanese medicine which viewed nursing
on a subvocational level. Under such a system, the low
level of esteem for nursing education at that time is under- standable.^' '"^^"'^
Developments in the Health Field
Taiwan was a target for devastating bombing during
World War II leaving the hospitals and schools of nursing in poor condition. Within this framework and after the war,
the government was faced with the problem of building ade- quate health facilities for the people and establishing educational programs to prepare nursing personnel. With the
282 . 283
assistance of the World Health Organization and some aid from
the United States, some health programs, health centers, and
stations were established. To meet the health demands of the
country, nurses were needed and hence an effort was made to
develop nursing education. This was achieved through a sur- vey carried by the Nursing Department of the National Insti-
tute of Health in 1946. A direct outcome of the survey was
the closure of hospital-operated schools of nursing, the establishment of a provincial school of nursing in Taipei for
the training of nurse-midwives , and the initiation of refreshe
' ''"^^ courses for hospital and clinic nurses .
Nursing Education
In reconstructing Taiwan after 1946, the government followed the educational system that existed in mainland
China then that was influenced by the British and American systems. Schools of nursing were established under two main categories, vocational and professional. Vocational nursing schools prepare nurses to function in hospitals and public health agencies. The three-year program requires students to be junior high school graduates with nine years of basic experience. The curriculum structure is based on the diploma programs which give equal emphasis to theory and practice.
These vocational schools, however, are limited to female, unmarried students under 22 years of age. Efforts are being exerted at present to recruit male students into these pro- grams. At completion of the programs, graduates are required .
284
to take the government examination in order to be licensed
which then allows them to take the title, Licensed Voaational 4:177 Nurse
Four-year baccalaureate programs and three-year
college programs are also available to prepare professional
nurses. Both programs require graduation from senior high
school with 12 years of basic education. These programs are
designed to prepare nurse- teachers for the vocational schools
and administrators for nursing service. The title Licensed
Professional Nurse is given upon successfully passing a dif-
ferent level examination. These graduates can go abroad for
a masters degree which entitles them to teach at the profes-
"7 "7 / . 1 sional schools. (See Table 1.)
In an attempt to upgrade the vocational schools of
nursing, the government adopted the five-year nursing program
proposed to the Department of Education in 1958. As a result
several nursing schools, named Five-Year Technical Colleges,
are now in operation. These schools are designed to prepare
clinical practitioners with a better foundation of clinical
knowledge. Graduates can take either the Vocational Nurse
or the Professional Nurse Final Examination which provides the
possibility of pursuing graduate level education if the individual desires.
The nursing profession recognized the importance of preventive health care early enough to require all schools
of nursing to include public health and public health nursing 285
M-l X a o > 60 •H rH x; (J EC O H 0 0)00 O M X a) •H O O u tn o •H (/) o C S O 3 •T-l r-l 3 U 2 1-) 4J XI 3 O Ph 3
CNI 4-) 0) r~ O X C o > 00 > rH •H X •H CO H rt o •a n! U X 0) •rj C c o o M H O •H CO O (0 w •H rH 3 d o nj <4-i o XI 3 o > 0) 0) Q) 0) o tn rH 3 X C 3 D- (U o Pi 14-J (1) U 60 B -fi 0) > 60 0) 4J •H rH 4J iH O C ffi O cn n) O >^ 0) 03 EC 05 U X u S-l O O o 3 o •H C/1 OJ •H 2 •rH C c 0) C CO •H O X •H •-3 3 B O 4-1 4J PL. nj 03 O -H CD 3 60 t3 <; o 0) 3
> x: 1-1 •H 60 0) t-l 4J 4-1 O (-1 •H •H ffi O n) CO 0) 00 O S Vj 60 d U X O O B •H CO o C u cod 0) <4-l s u z X C/1 3 -a pj 0) 4-1 D- nJ
03 4-> c l4-< 0) 60 O 60 O 60 0) B C C C / o
in their curricula. All nursing students also gain some
public health experience through the hospital outpatient
departments and the followup home care program. In addition
a twelve-month course in public health is made available by
the Provincial Junior College of Nursing for graduate nurses who have had at least one year of public health experience.
Scholarships are also available for graduate nurses inter-
ested in pursuing a public health specialists degree in the
United States, the United Kingdom, or Japan. This was accom- plished in view of the tremendous shortage of public health nurses needed to serve in rural areas.
Midwifery in Taiwan
The practice of midwifery in Taiwan is governed by the Law for Midwives which is set up by the government. Home delivery and natural childbirth are much more popular than hospital delivery in Taiwan. As a result, midwives in pri- vate practice conduct the complete prenatal examination and are responsible for the pregnancy, delivery, and postpartum periods. Midwives are presently prepared in many ways: a four-year bachelor's program, a three-year junior college program, a five-year nursing combined with midwifery program, a four-year nursing combined with midwifery, a three-year nursing program and a one-year midwifery program offered only to registered nurses. Midwifery as a profession is highly respected by society in Taiwan and hence attracts a large number of students "'"^^'^ . ,
287
Nursing in Taiwan has gone through extensive changes
in quality and quantity since independence. Within this
period nurses have become university and college graduates,
and nursing as a career has faced radical and rapid expan-
sion in its structure which allows it to provide more and
better service to the society it serves.
Health Services in Taiwan
Public health services in Taiwan are administered at
four governmental levels: national, provincial, county or
city, and township. Each of these levels has its own health
organization. The National Health Administration (NHA)
established in 1971, is the highest authority at the national
level. Under jurisdiction of the Executive Yuan, it deter-
mines health policies, formulates health programs, and super-
vises and coordinates health services at all levels. One
provincial health department and one city health department
are under direct supervision of NHA. These departments are
responsible for the planning of public health and medical
programs and the supervision of health activities of subordi- nate governments. Both public and private sectors render medical care services in Taiwan. The government provides free or subsidized medical services only to indigents; the rest of
the population is responsible for its own medical care 5:3-8 services
The Provincial Maternal and Child Health Institute was established in Taiwan in 1959. This institute, during recent 288
years, has put into practice different projects that deal with maternal and child health services. Antenatal, post- natal and child care clinics are the main activities of the maternal and child health stations scattered throughout the
country. In addition, home visits are made regularly by
the nursing staff, thus providing health supervision of the
family as a whole. A considerable improvement in family planning has been witnessed as the result of the intensive home visit program of the public health nurses of the local health units. The Maternal and Child Health Institute is responsible for the training and supervision of the local ^-^^"^^ MCH workers.
The Provincial Health Department has the overall responsibility of public health services in Taiwan that include curative and preventive health services and in- service training of personnel. It is also responsible for supersivion and planning of the county health bureaus and the health stations. The health bureaus are responsible for all the health services in their specific counties and cities.
A health station usually serves a population of between
20,000 and 50,000. Its personnel are composed of one or two doctors, two to five nurses and midwives, and one to four health workers. ^
The national Health Administration of the Republic of China has developed a plan to construct more health facil- ities and to expand existing health stations to better serve .
289
the people of the area. Health education has played an important role in the improvement of the health care delivery system. Through health education, the people have realized their own health needs and hence have cooperated with their own communities to strengthen the already existing health programs 290
References
1 Chang, C.T. Maternity care in Free China. Bulletin of American College Nurse-Midwife^ 1968^ 13, 139-42.
2 Jameison, E., Sewall, M. and Suhrie, E. Trends in nursing history (6th ed.). Philadelphia: W.B. Saunders, 1966.
3 Li, S.F. Public health nursing in Taiwan. Republic of China. American Journal of Public Health, 1966^ 56, 492-8.
4 Lo, M.C. The education and the role of the nurses in Taiwan. International Nursing Review, 1973^ 20, 176-7.
5 Republic of China. Taiwan's health. National Health Administration, 1974-1975. PART VI
AFRICA CHAPTER 21
SOUTH AFRICA
The South African Republic was sparsely populated with the greater number of the population living on farms.
Only when gold and diamonds were discovered were towns built and populated. This resulted in a thin distribution of medical practitioners all over the area. However, most of the medical and all of the nursing care then was done by the women of the household. The seasonal outbreak of malaria in 1878 and the annexation of South Africa to
Britain, a move that brought many gold diggers, led to the opening of two emergency hospitals in the area. Women of the nearby villages, headed by a Mrs. Robins, took on the 12 3-4 nursing of the malaria patients at these hospitals. •
Early Nursing Developments
At about the same time. Sister Henrietta arrived in
Africa from England to join the sisterhood of St. Michael and All Angels. Six years later she undertook to train nurses of the area who until then had been honorary helpers,
Trained nurses were later sent to different parts of the 4-27 country stricken by epidemics of communicable diseases.
With the discovery of gold in the Republic, an economic
292 6
293
boom resulted and public revenue increased rapidly. This resulted in an increase of Dutch and English medical prac- titioners who on their part pressed for more hospital facilities. All this contributed to a decision by the government to establish subsidized hospitals, which contrib- uted to the increase in number of medical care facilities,
the appointment of more medical consultants , and education
^ . 4:27-8;12:86-7 of the nurses m formalf T schools.u ^ Sister Henrietta's training methods included lectures by herself and by local doctors and surgeons on anatomy and physiology, practical nursing and cooking. At the end of the first year of training, nurses were promoted to staff nurse but continued training for another year, at completion of which an examinatuon was administered. After a third year of training, nurses received a certificate which entitled them to be registered with the British Nurses' Association.
In 1891 South Africa was the first country in the world to
8 A 1 pass registration laws for nurses. ' This was attributed to the efforts of Sister Henrietta who insisted that nurses should be given legal standing as properly qualified nurses, as distinct from volunteers. As a result nurses were placed on the register of the Colonial Secretary's Office through 12 86-8 the Medical, Dental, and Pharmacy Act.
Nursing Organizations
On the termination of the South African War and the signing of the Peace Treaty of Verceniging, South African 294
Republics became British possessions. In 1910 the four
colonies merged into a union of four provinces. A consol-
idating law was passed at the same time which controlled
the practice of medical practitioners, dentists, chemists, druggists, nurses, and midwives . The first South African
Trained Nurses' Association, founded in 1914, was repre-
sented by nurses and midwives on the South African Medical
Council which demonstrated an important example of doctors ^"^ and nurses working together harmoniously and effectively '
In 1944, in spite of many difficulties, a charter
was granted by the government which established the first
South African Nursing Council ^and the South African Nursing
Association, replacing the South African Trained Nurses
Association. These two bodies together regulate the affairs
of the nursing profession, the first being responsible for
specifying the curricula, supervising the standards of
nursing schools, and granting registration, and the second
advising the Ministry of Health on nursing matters and
^"^ • '^•'•^"'^ working ^ ' ' ^ for the welfare of its members .
Nursing Education
From 1900 to 1948, nursing and midwifery training
was provided in a series of hospitals and nursing homes
ranging from private, profit-making, missionary, to State
subsidized institutions. An apprenticeship system existed at that time by which student nurses signed a contract with a hospital board to serve three and a half years 295
during their training period, leaving little scope for the 3-9-10 development of a truly educational program. ' Soon
after the second World War, the majority of nursing schools
in South Africa were associated with a nursing college.
Each nursing college was an educational center or teaching
department which provided theoretical instruction for
students from different hospitals and maintained close
supervision on the clinical practice. After three and a half years in the basic nursing course and upon passing the
final examination the student became a fully pledged regis- 3:10;10 tered^ nurse ... In order to prepare nurses for community work or other than hospital bedside care, a basic degree program was developed in 1956 by the University of Pretoria.
A Bachelor of Arts and a Bachelor of Science degree in nursing were established within the Faculties of Arts and
Sciences. Both programs were four and a half years long at the end of which graduates were registered as medical and surgical nurses. The training in both programs was patient-centered, requiring nurses to be enrolled at the
Pretoria Hospital as staff members. This was done mainly to emphasize the team concept early in the students' train- ing and to develop responsibility from the start.^ Candi- dates for both programs had to meet university admission requirements. The nursing content of the B.A. and the B.S. courses is the same. One, however, is weighted on the side 296
of the social sciences, while the other focuses on the
, . , . . . 9:1401 physical sciences in nursing.
Bantu Nurses
Although the training of white nurses was expanding rapidly, Bantu women were still receiving on-the-job training as nurse aides until the beginning of the twentieth century.
This was attributed mainly to tribal prejudices, lack of sufficient high schools, the poverty of the people, and the tendency among the Bantu parents to give preference for
12 * 260 education to their male children. ' Training facilities for South Africa's Bantu girls are expanding rapidly. Train- ing colleges for nurses with the same admission standards, requirements, syllabi, and examinations are being established throughout the Republic and an increasing number of Bantu women are adopting nursing as a career. Because of the
Republic's segregation laws, coloured Indian and Bantu cannot train with white people and hence, each group has its own colleges and training schools. General as well as postbasic nursing training is available in some 20 different courses, including nursing administration, clinical care, instruction,
^'^^ '"^ ^ " ^ ' and midwifery programs . '
Though Bantu men had served as orderlies in non-white hospitals since 1856, no attempt was made to train them.
However, in 1927 a course was introduced at the hospital to train male nurses to relieve female nurses on male ^"'"^ wards. ^'^Some Bantu male nurses were employed as " 9
297
health inspectors by the Department of Health to work in the 12 268- Bantu Reserves or in the Indian Townships.
Trends in Nursing Education
. . In addition to the above-mentioned basic courses, two types of basic midwifery courses are presently available in the field. An eighteen-month course is offered to persons
not qualified as medical and surgical nurses . The other is a nine-month course for registered nurses only. The standard of admission to the basic nursing school which includes pro- grams in mental and mental defective nursing has been set at
"'"'^ a minimum of ten years of general education .
In 1956 the University of Pretoria, upon the recom- mendation of the medical faculty, transferred the Bachelor of Arts nursing degree to the College of Medicine thus establishing a Department of Nursing Science within this faculty. Soon, six other universities established inte- grated baccalaureate nursing programs, two of them using
English as the language of instruction and the others using
Africaans 11- 108-9 However, all students use both languages in addition to a third foreign language. Also, unique to the university program in South Africa, of which nursing is an integral part, is the requirement of two majors for the '^^"^ degree , nursing being the second major
Postbasic education programs are also available in clinical nursing fields and in administration and teaching fields. Clinical training at present focuses on 298
operating-room techniques, ophthalmological nursing,
pediatric nursing, neuro-psychiatric nursing, surgical
nursing, orthopedic nursing, public health nursing, and
occupational health nursing. These courses are adminis-
tered at hospital schools of nursing or at technical col-
leges depending on the nature of the course. Training in
the administrative and teaching fields, available for ward
sisters and clinical instructors, is usually conducted at
the loniversity level and extends one to two years.
Refresher courses for hospital nurses, offered also by local
hospitals and schools of nursing, have contributed a great
"'"^ ' "^^^"'^^ ' -'^ '^'-"^ deal to the quality of nursing care given .
In addition to the baccalaureate degrees in nursing, masters and doctoral degrees have been introduced at some universities in the country and are known as Master Curationis and Doctor Curationis , referring to a special healing func-
tion a nurse possesses. This has placed the nurse on a status that shares full partnership with the medical practi- tioner in the health care arena. Master's degree programs in nursing, available now in nursing education, nursing administration, and clinical nursing, have common core sub- jects with postgraduate medical students. The doctoral degree, however, is a research degree with study in depth of two aspects of nursing "^^"^ '-•'•^"•^
The curriculum of the baccalaureate degree extends for four and a half to five years and all universities 299
require student nurses to be student members of the hospital
staff and other health agencies where experience can be
obtained. Ward staff share in the supervision of clinical
experience; however, a major part of the clinical instruc-
tion is by the university personnel. A three-year baccalau-
reate program was introduced in 1970 by the University of
Pretoria for registered nurses with the purpose of assist-
ing this group to meet modern nursing challenges. Other universities, ever since, have introduced such a program
into their curricula which have attracted many nurses will- '^^"-^ ing " to accept the challenges . 300
References
1 Bauman, M.B. Baccalaureate nursing in a selected number of English speaking countries. International Nursing Review, 1972, 19, 12-38.
2 Beal, B. Bantu nursing. American Journal of Nursing, 1970, 7^?, 547-50.
3 Bridges, D. A journey to Africa. International Nursing Review, 1955, 2, 7-13.
4 Bull, M.R. Kimberly: a century of nursing. Nursing Mirror, 1971, 125, 27-30.
5 Bull, M.R. Training South Africa's nurses. Nursing Mirror, 1971, 1S2, 18-20.
6 Erasmus, C. Experiences of an exchange-visitor-nurse. International Nursing Review, 1967, 14, 42-4.
7 Fendall, N.R. The medical assistant in Africa. Journal of Tropical Medical Hygiene, 1968, 71, 83-95
8 Goodnow, M. Nursing history (9th ed.). Philadelphia: W.B. Saunders, 1955.
9 Grobellaan, A. South African experiments with the basic collegiate program, American Journal of Nursing, 1958, 55, 1401-2.
10 Roberts, E. Nursing in Johannesburg. Nursing Mirror, 1969, 125, 39-41.
11 Searle, C. Developments in nursing education at South African universities. International Journal of Nursing Studies, 1969, 6, 107-13.
12 Searle, CM. The history of the development of nursing in South Africa. Cape Tov/n: Struik, 1965.
13 Searle, C.S. Nursing education in South Africa. Inter- national Nursing Review, 1957, 41, 49-62. CHAPTER 22
NIGERIA
In Africa a vast number of preventable diseases
still exists and the standard of positive health is highly unsatisfactory. Poverty, illiteracy, ignorance of the . people, poor sanitation and lack of medical care contribute
to the health problems. Hence, before attempting to treat
disease, the social conditions that have caused it must be attacked. All the above factors provide a challenge for the provision of medical and nursing care in the developing countries. Since the number of physicians available is inadequate, many tasks that would otherwise be done by them are carried out by nurses or other paramedical personnel.
In such a context, one can find many interesting experiments with the use of health-related professionals taking place in
'''^ '-^ most of the developing countries . "
Like other English-speaking countries among the developing nations, organized health services developed in
Nigeria at the turn of the present century. Originally, such services were meant for military men and their families and included European traders and missionaries. Gradually, the services were extended to the African population through
301 302
establishment of government clinics and hospitals. A sharp
distinction existed between the curative and preventive
services with the government taking responsibility for cure
and the local authorities of prevention. All physicians
then were trained overseas, for no medical schools were
available in the country, explaining the scarcity of doctors
. . , 12:159 at the time.^.
Development of Modern Nursing
Nursing in the sense of helping has a long and
traditional history in Nigeria. Formal training of profes-
sional nurses was based on the British system and continues
to the present to dominate and influence the philosophy and
. ^ " curricula of most schools of nursing ^^^^ Apart from
training obtained in Nigeria, many Nigerians went to the
United Kingdom to undergo the three-year course there, fol-
lowed by a year of either midwifery or public health.
Registration of nurses and midwives in Nigeria started as early as 1910 but Midwives' Board of Nigeria and the Nursing Council of Nigeria were not established until
^ 1930 and 1946 respectively. ' These two bodies, through the efforts of their leaders, have contributed a great deal to raising nursing standards throughout the country and to adapting ''^ nursing " curricula to the people's needs .
Nursing Education
At present. Federal- and State-operated nursing schools are abundant throughout the country. All these 303
schools are tuition-free, and all qualify their graduates
for registered nursing certificates that are recognized in
Nigeria and throughout the United Kingdom. Generally men
are not encouraged to join the profession, although one
all-male nursing school exists near Lagos. To be admitted
to any one of the diploma schools, candidates should have
the secondary school diploma and should be fluent in English
in addition to the native language. A high score on the
common entrance examination given by the Nursing Council is
also required. The entire teaching scheme is patient-
centered focusing not only on the care of the sick, but also
on the prevention of disease.
In 1950, a midwifery school was established by
British nurses which trained graduate nurses in a one-year program. At the end of training, students were permitted
to take the examination set by the Nigerian Midwives' 15 1664 Boa^d. Similar schools were established to train domiciliary midwives in an effort to meet the country ' s needs
1 0 for health services in the rural areas. Under the same goals, health centers were built in rural villages and com- munity health nurse emerged whose training adapted well to the needs of the health center. Candidates for these programs are required to have had a minimum of nine years general education before they are admitted to the three-year training combining essentials of midwifery, nursing, child care, and health visiting. Such programs are also made available to 304
midwives who are required to go through a one-and-a-half-
year course before qualifying as community nurses. To
assure proper and continuous health services, candidates
are recruited from the rural areas. They remain in close
touch with their own communities and thus are more likely
'''^ "^^^ to remain in those areas . '
Many children under five years were dying of infec-
tion, malnutrition, and ignorance. To meet these pediatric
challenges the child health nurse came into being. Nurses
in the area make primary decisions, see and manage a large
number of patients with uncomplicated illness and refer
the few complicated cases to physicians. This new role has
expanded the functions of nurses in Nigeria and raised the
standards of the profession in the country. The child health nurse is usually an experienced registered nurse whose
experience has been enhanced by a few additional cours-es on assessment and diagnosis of major and minor health prob-
lems. These functions are conducted in a clinic under the
.'-^ help and ^3; 12 : supervision of a responsible physician • 171
One year after Nigeria achieved full independence, the Federal Ministry of Health initiated official action that resulted later in the establishment of a postbasic nursing program at the University of Ibadan. With the help of the World Health Organization, a survey of the nursing conditions was conducted which made special reference to the lack of an adequate number of nursing schools and to the '
305
need of upgrading nursing education."^ As a result of a joint
effort among the World Health Organization, the Rockefeller
Foundation, UNESCO, and the Nigerian Government, the first
Department of Nursing within the Faculty of Medicine was
founded in 1964 at the University of Ibadan. The baccalau-
reate nursing program, which admitted its first students
in 1965, is a three-year course focusing on the integration
of theory and practice. The courses are specifically
designed to prepare students to work in the areas of teach-
ing, administration or research in nursing. Throughout the
curriculum, theory and practice are adapted to the needs
of the indigenous locale and culture, thus rendering it more
. ^ pertinent and useful '
Because so many preventive aspects of health care are
carried by nursing personnel, all nursing curricula in
Nigeria at all levels focus on this important part of the health care delivery system.^ Some schools have devised a
special postgraduate course in public health or community health nursing in an attempt to meet the growing needs of the population. In addition, most of these programs integrate prevention into all their nursing courses so that students will have a broad idea of what preventive medicine means and how positive health can be achieved. These nursing concepts help the nurses educate the public on the nature of disease ^ and the different ways it could be prevented.^ ' ,
306
Nurse Training Today
For a student wishing to enter the nursing profession
in Nigeria, four basic level programs are available:
(1) A three-and-a-half-year general nursing course is offered in schools of nursing attached to hospitals or University Teaching Hospital... This prepares the nurse to take the Nursing Council examination at the end of the program. Graduates who have completed the new standard of nurse education, introduced in 1965, are registered as Registered Nurse (Nigeria) or
(RN Nigeria) , while graduates of the old program are registered as Nigerian Registered Nurse (NRN). However, both groups are desig- nated as staff nurses on employment. The new program provides for general basic training including courses in applied, general, and social sciences. This enables student nurses to choose their area of specialization early in their schooling .15:30
(2) A two-and-a-half-year course in midwifery is available at Maternity Hospitals Schools of Midwifery. Upon completion of the course the student is registered as Nigeria Certified Midwife (NCM), and carries the title of staff midwife on employment . 15 : 30
(3) A three-and-a-half-year community nurse training course is also available. It is a comprehensive program in public health nursing which includes health education and midwifery. Graduates of this course are registered as Nigeria Registered Community Nurse (NRCN) and also receive the midwifery certificate. Community nurses fianc- tion in public health and preventive areas such as domiciliary health services, health centers, and infant welfare clinics . : 30
(4) A three-and-a-half-year training course in psychiatric nursing is offered at the Hospital for Nervous Diseases. Upon passing the qualify- ing examination, graduates of this course are registered as Nigeria Registered Mental Nurse (NRMN)A^'^O
The RN (Nigeria) graduate, after a few years of experience can take postgraduate courses in teaching, 307
administration, obstetrics, or research. However, most graduates take the one-year midwifery course. Nurses in
this category who wish to go further can become health visitors by entering public health schools of nursing.
The health visitor in Nigeria works with the family teaching 3 higher standards of health prevention. The Bachelor of
Science degree program at the University of Ibadan is another challenge for general trained nurses, providing opportunities for further study at the university level. Graduates of this program are prepared to serve as nurse educators or administrators in hospitals, schools of nursing, public health agencies, and similar institutions in the country . ''"^ ' '^'^ 308
References
1 Birch, J. A. Nigeria in peace and war. International Journal of Nursing Studies, 1971^ 8, 145-52.
2 Bringing health to the nation. Occupational Health Nurse, 1974, 22(10), 23-4.
3 Chokrieh, A.C. Change in nursing in Nigeria. Inter- national Nursing Review, 1975, 22(3), 71-9.
4 Clemence, B.A. Baccalaureate nursing education in Nigeria. International Nursing Review, 1971, 18, 40-8.
5 Davis, A.J. Health problems and nursing practice in Sub-Saharan Africa. International Journal of Nursing Studies, 1975, 12(2), 61-4.
6 Davitz, L.J. Becoming a nurse in Nigeria. American Journal of Nursing, 1972, 72, 2026-8.
7 Dosunmu, N.E. Nursing as a career in Nigeria. Inter- national Nursing Review, 1973, 20(1), 30.
8 Duke, E.O. History of nursing in Nigeria. The Australian Nurses' Journal, 1967, 65, 34-6.
9 Hamilton, J. Nursing in Northern Nigeria. Nursing Times, 1966, 62, 259-60.
10 Mojekwu, V. Pediatric education for Nigerian nurses. Journal of Tropical Pediatrics, 1975, 21(1-B), 72-3.
11 Muir, M. Nursing in Nigeria. Nursing Times, 1967, 63, 530-1.
12 Pratt, R. The challenges of nursing in developing coun- tries. International Nursing Review, 1970, 17, 158-71,
13 Radwanski, D. Occupational health services in Nigeria. International Nursing Review, 1972, 19, 283-8.
14 Timmins , N.G. Nursing against the odds. Nursing Times, 1965, 61, 1763-4.
15 Turtill, B.M. Midwifery and midwife training in Nigeria. Nursing Times, 1965, 61, 1664-5.
i CHAPTER 23
MOROCCO
Morocco displays a blend of past civilizations that
left only traces in the sand on their disappearance and hence makes up today's Moroccan culture. Although it is a Moslem-
African country whose people speak and write Arabic, it is
neither African nor typically Arabic or Moslem. ' In spite
of many obstacles, Morocco has made tremendous progress in
developing health facilities to meet the needs of the country.
The health center comprises the main unit of health services, which can be urban or rural. Local dispensaries branch out of this health unit to serve subdivisions of the population.
In these dispensaries nurses keep a continuous check on the
1-23' health care of the community.
Nursing Education
Nursing education in Morocco is under the Ministry of
Public Health which takes the responsibility in training and employing nurses. The Office of Professional Education, that directs and supervises schools of nursing, prepares both registered nurses and auxiliary health personnel. Out of twenty-eight schools responsible for the training of allied health personnel, one grants a postbasic degree in nursing,
309 310
four grant the general nursing diploma, one offers a certif-
icate in obstetric nursing, one in neuropsychiatry, and 1*23 fifteen train nursing auxiliaries.
Candidates admitted to the diploma program in
nursing must have six years of secondary education, be at
least eighteen years of age, and pass the entrance examina-
tion to the school. Auxiliary nursing students must pass an
entrance examination and should have completed three or four
years of secondary education. Upon completion of two years
of practical experience, auxiliary nurses, if they desire to
change their nursing status, are permitted to take the en-
trance examination of the schools for registered nurses as
well as certain courses given by correspondence. On the
other hand, registered nurses with one year of experience
in nursing can take the entrance examination to the postbasic
school of nursing in addition to some correspondence courses ^"'^ offered by the school ^
The two-year curriculum for registered nurses in- cludes courses in general culture, social and human sciences, biological and physical sciences, pathology and nursing, and public health, including family planning. The post- basic program, also two years long, focuses on specialty courses in education, administration, social welfare and obstetrical nursing, in addition to the advanced courses offered in the registered nurses' program. Auxiliary nurses are trained for nineteen months during which theory 311
, • . 1:24; 2:325 and practice are integrated.^ ^ These programs are conducted by specialized instructors from the postbasic school or by registered nurses who went abroad for special- ization. The curricula of the three types of nursing schools stress prevention and positive health. Since all Moroccan public health services are integrated, nurses at all levels,
in urban or rural areas , are expected to participate in the prevention of communicable diseases, health education, mater-
1 • 24 nal and child health care, and family planning.
In light of the emphasis on continuing education for nurses to assure a better health care delivery system, the
Ministry of Public Health has set up provincial and district committees to establish inservice and continuing education programs. These committees see to it that all nurses take part in the programs offered. The standard of care in hos- pitals is evaluated regularly by the Central Technical Ser- vices of the Ministry of Public Health whose staff is con- posed of doctors and nurses competent in their areas. This is made possible to ensure that proper health care is avail- able to the general population.
Noteworthy is the fact that 50 percent of Morrocan nurses are men who consider nursing to be a worthwhile pro- fession. Many of the male nurses, however, continue on to
• 2 ' 330 become doctors. 312
References
1 Moutou, L. A glimpse at the nursing profession in Morocco. International Nursing Review, 1915, 22(1), 23-4.
2 Rogers, C. Morocco: an exotic land. AORN Journal, 1975, 21(2), 324-30. .
CHAPTER 24
GHANA
Early Nursing Developments
The care of the sick in Ghana was always carried by
elderly female members of the community whose skill was
acquired through experience in housekeeping and child rear-
ing. Professional nursing dates from the colonization of
the country by Britain in 1844. British physicians took
care of the colonial administrators, and mission doctors worked among the pagans they were assisting to turn to
Christ. Many male orderlies enlisted with the missionary
groups to help bathe and feed the sick. Later, these
orderlies were trained by physicians to dress wounds -id
administer simple drugs. Recruitment of female nurses for
this type of work was impossible, for families regarded
• 3:205 nursing as an unsuitableui profession^ forf young women.
Training in simple nursing tasks began in 1899 by a British
Colonial sister who organized an inservice program to train
the orderlies, already in practice, for senior nursing posts mainly held until then by the Colonial nursing sisters of
. 3:206-7 Britain„
313 314
Nursing Education
The first midwifery training school was established
in 1928 in Accra and high school students were recruited for
midwifery training. Upon graduation, the newly trained mid-
wives assumed staff nursing positions in maternity hospitals
or went into domiciliary midwifery. In 1931 the Midwives
Board was established which brought into force the legisla-
tion for the training, examination, registration, and prac-
• tice of midwifery. 3
In 1944, the first curriculum for the training of
State Registered Nurses was established. The training of
local girls followed the general standard practiced in
England and Wales at the time. This made it possible for
locally trained nurses to be registered in Britain. Another
curriculum was drawn up during the same period for the train-
ing of candidates in mental health nursing. In addition,
a public health nurse- training program was started to prepare nurse-midwives ^ ^•''^ in a one-year postbasic course . '
Nursing Legislation
The Nurses' Board of the Gold Coast and the Nurses' Ordinance were established in 1946. This came about as a result of legislation introduced to govern the standard of training of State Registered Nurses, Qualified Registered
Mental Nurses, and Public Health Nurses, their examination, registration, and code of practice. As a result, examination and registration were done on a national basis, with the 315
Board supervising the practice of nursing and taking disci- plinary action when deemed necessary. At present, three nursing divisions exist in the Ministry of Health in Ghana.
One deals with nursing education, one with hospital nursing service, and one with public health nursing service. The head of the main division is the Chief Nursing Officer who is assisted by the heads of the three subdivisions. The employment of nurses of all grades in the government service is done by the headquarter offices in Accra that plan the
• 3 " 212 allocation of nurses according to need.
Health Services
Health services are available at health posts in remote rural areas through health centers, district hospi- tals, regional hospitals, and central hospitals that offer all the specialist facilities. A typical health post serves a population of 10,000 to 15,000 and is usually staffed by a health post attendant, health inspector, community health nurses, and a midwife. Home visiting and preventive care are by the midwife and the community health nurses. The number of personnel, as well as the sophistication of their training, increases as one moves up the hierarchy in the health care delivery system. Patients are constantly referred from the health posts to the health centers for more specialized treatments and care.^'^''"^ 316
Nursing Personnel and Their Training
Two categories of nursing presently exist in Ghana:
a professional nurse, who is the State Registered nurse, and
the auxiliary nurse, who performs the less skilled nursing
duties. The curriculum for the training of State registered
nurses includes psychiatric, public health, and obstetric
nursing in addition to the basic nursing courses. In 1963
a postbasic Department of Nursing was established at the
University of Ghana at Legon for higher nursing education.
This was made possible through a tripartite agreement of the
World Health Organization, the Government of Ghana, and
UNICEF. Two-year programs are offered in nursing education
and administration. Nurse tutors are prepared to teach
general, ' mental, and public health nursing, and midwifery .
Two categories exist in the training of auxiliary nurses: the enrolled nurses or nursing assistants who work
in institutions, and the comjnunity health nurses who are assistants to the public health nurses with special train- ing in maternal and child health, who work in rural areas.
Since the majority of problems in Ghana are categorized as public health problems, the Ghanian public health nurse and the community nurse have proved to be extremely valuable in
' ^''^"^ meeting ^ ' the health needs of the country . '
Public health nurses in Ghana are known as medico- social workers, health teachers and family advisors. They have knowledge of child care, social and welfare services in 317
the community which qualifies them to properly assess the
health needs of the family through home visits and followup
care. Since much of the health care falls on nursing per-
sonnel, all nursing curricula focus on prevention and posi-
, 2:63;5:1056 tive health. '
In 1970, through the foresight of a group of medical
doctors, the government embarked on a family planning program
and a nurse-midwifery training school modeled after the pro-
gram at Downstate Medical Center in New York. The curriculum
prepared midwives on methods in family planning and their
implementation. Family planning nurses have done an exten-
sive job in instructing women in rural areas on modes of
contraception as well as in carrying on the routine physical ^ ^^"^"^ ' examination and tests for preventive measures "
Trends in Nursing
The preparation of nurses in Ghana is undergoing
change continuously. Basic nursing curricula are being
revised and more postbasic programs are being added.
Inservice education as well as continuing education are gaining in popularity to the extent that they are being enforced by the government. Nursing at the graduate level is becoming popular and nurses are leaving the country for the United States to seek higher education in nursing.
All these developments in nursing education, which have taken place over a short period of time, speak for the promises the nation holds for the nursing care in the future. 318
References
1 Addo, C. The midwife in family planning. Nursing Mirror, 1971, 34-5.
2 Davis, A.J. Health problems and nursing practice in Sub-Saharan Africa. Interyiational Journal of Nursing Studies, 1975, 12(2), 61-4.
3 Kisseih, D. Developments in nursing in Ghana. Inter- national Journal of Nursing Studies, 1968, 5, 205-19.
4 Pendleton, E.M. Ghana looks for the future. Bulletin of American College Nurse Midwife, 1972, 17, 78-81.
5 Swaffield, L. Blending the best of both worlds — Nursing in Ghana. Nursing Times, 1974, 70, 1056
6 Twumassi, P. A. Scientific medicine — the Ghanaian expe- rience. International Journal of Nursing Studies, 1972, 9, 63-75. CHAPTER 25
EGYPT
Egypt is one of the most ancient and best known
lands of the African continent. The innovation of a govern-
ment program for the training of women medical aides was
established early in the nineteenth century. It started as
a rudimentary national health service and has continued to
grow ever since. A School of Medicine was founded in 1827 to
train Egyptian physicians. In 1832 medical instruction was
extended to young women. This school was the first of its
kind in the Middle East that trained women medical aides.
At that time Egypt was still a medieval Muslim society where
the place of women was mainly controlled by tradition and
culture. However, with the outbreak of communicable dis-
eases, women were needed to do community health work. This
led a Dr. Clot in 1832 to establish a public health program and to train women ^ '^^"'^ to become Hakimas or doctors . '
The Hakima School
The school founded to instruct women medical aides in Egypt was referred to as the Midwifery School for it emphasized obstetrics and infant care. The six-year course included much rudimentary theoretical science, an impressive amount of instruction for that period. Many obstacles faced 319 320
Dr. Clot in his attempt to develop the program. Finding
candidates was his major problem. Egyptian parents at the
time did not allow their daughters to work outside the home.
However, with time and endurance many young women became
interested in the work other Hakimas were doing and joined
All students in the Hakimas program, like other
students in Egypt, were housed, fed, clothed, and instructed
at the expense of the State. Upon graduation from the pro-
gram, honor students were automatically appointed assistant
instructors, whereas the others were assigned to duty in
Cairo Civil Hospital and in health centers in various parts
of the country. Generally, the Hakimas remained in senior
student status, without promotion in rank or advance in
salary, until they were married. This heavy-handed paternal-
ism on the part of the government threatened the existence
of the Hakima school, for few women were interested in leav- '^^"^ ing home for ^ ' what they considered a menial occupation .
The first step in broadening the school's activities
occurred when the school for Hakimas was annexed to the Civil
Hospital in Cairo. There, the Hakimas were able to work with
indigent patients at the outpatient clinics of the hospital.
They also organized a team responsible for controlling commu- nicable diseases through immunization and education. The
Hakimas and their school survived into the twentieth century
and today continue to function in the Egyptian public health 321
establishment. What the Hakimas performed at that time of
history is remarkable, especially since women and children
were virtually inaccessible to physicians. The Hakimas'
training center was the only State school for women in the 2 ^198-200 country.
The Beginning of Modern Nursing
In 1882 and under the British occupation of Egypt,
professional nursing was introduced. It emphasized hospital
training and was mainly dominated by Europeans. Egyptian
women, with the exception of Hakimas, remained at home and
practically ^ ' 2*^^"-^ outside society in general . One of the
earliest schools in North Africa is attached to the large
Kasr-el-Ainy Hospital in Cairo, which has attracted and
trained a large number of nurses from the region. British
matrons and sisters administered the hospital for many
years. However, this responsibility was later transferred
" to Egyptian nurses .
The Higher Institute of Nursing was established in
Alexandria in 1955 with the assistance of the World Health
Organization. With the objective of raising the health
standards of the country, the Egyptian Ministry of Health
and the medical faculty of the University of Alexandria cooperated with the World Health Organization to help establish the Institute. The program leads to a baccalau- reate degree in nursing, emphasizing public health nursing as well as other aspects of nursing. At the beginning the 322
teaching staff was provided by the World Health Organization
However, with time, and with the availability of fellowships
and scholarships by the government and other international
agencies, Egyptian girls were sent abroad for specialization
Eventually, these nurses assumed leadership roles in nursing ^^^"^ " schools and hospitals .
Nursing Education
At present many schools of nursing offer the four-
year baccalaureate program in nursing. A one-year intern-
ship in a clinical area is required after graduation from
the program, to consolidate experience before responsibil-
ities are assumed. Another fairly recent program in Egypt
is a course that brings nurse trainees and medical students
together in joint sessions reflecting the growing apprecia-
tion of the medical profession in what nursing is doing at present. "'"^'^^ Many of these graduates have gone to the
United States seeking graduate degrees at the masters and
doctoral levels and on their return to Egypt, contributed in raising the standards of their profess ion "'^'^^
Some graduate programs in preventive health and nursing are offered at some universities in Cairo. Diploma nursing programs as well as auxiliary nursing programs still exist in large numbers in Egypt. Most of these schools fol- low a standard curriculum under the Ministry of Health. The
Egyptian Nurses' Association became a member of the Inter-
= ^^^^^ : 459 ^ ^ 3 national Council of Nurses in 196I . 323
References
1 Bell, J. Leadership and responsibility. Nursing Times^ 1973, 69, 1542-3.
2 Kuhnke, L. The doctoress on a donkey: women health officers in nineteenth century Egypt. Clio Medioa, 1974, 9(3), 193-205.
3 Stewart, I. and Austin, A. A history of nursing. New York: G.P. Putnam's Sons, 1962. CHAPTER 26
RHODESIA
Traditionally nurse training in Rhodesia was mainly-
practical. Today, however, with increasing specialist demands
on the medical profession, nurses are prepared to accept more
responsibilities by acquiring more medical knowledge through
theory and practice. ' The first African students started
to train as registered nurses in 1959. They were chosen for
their ability to read and write and to understand the English
language sufficiently to follow the three-year course without
difficulties. Prior to that most nursing was done by mis-
sionary sisters and doctors who settled in Rhodesia late in 3-53 the nineteenth century. "
Nursing Education
The training of nurses at present is modeled after
the British system. This has ensured registration of graduate nurses in Britain and allowed for nurses to enroll in post-
graduate courses which are not available in Rhodesia. The
training of male nurses for registration started in 1964, increasing in popularity ever since. Training programs are for three years and follow the same admission requirements and syllabus as that of the British. However, the different 324 325
diseases, social, and cultural conditions common to the
country take up a major portion of the schools' curric- ula.2^9-10;3:53-4
Student nurses spend the first eight weeks of train-
ing in the school in an introductory course covering sub-
jects such as anatomy and physiology, first aid and physi-
otherapy, administration and nutrition. Nursing theory and
nursing practice are offered. Courses are planned follow-
ing the block system of education with students alternating
classroom instruction with clinical experience. During the
training period students return to the school for four other
blocks of four weeks each and another two-week block to
• prepare ^ ' them to take the State final examination .
Midwifery and psychiatry training are also available
in Rhodesia. Both courses are offered in two-year programs
to graduate nurses, and like the general course of nursing, follow the British scheme of training. Upon graduation, nurses are registered with the Medical Council of Rhodesia ^ ^^"^ and • with the Nursing Council in Britain . ^
Advanced Nursing Education
Rhodesia, like other countries of the world that are aware of the need for different categories of personnel on the health team, has launched a program to train Advanced
Clinical Nurses to replace the medical practitioner in rural areas. This training is under the auspices of the Medical Council of Rhodesia, a statutory body concerned with . 326
education, registration, and discipline of the whole health team in the country. The two-year course, offered at Mpilo
Central Hospital, is open to nurses who hold the general and midwifery training qualification and who have had at least two years of practical experience. The curriculum includes experience in community medicine, obstetrics, gynecology, neonatal care, family planning, anesthetics, clinical medi-
J- . • 1:243-4 cine, clinical surgery, and clinical pediatrics.
Upon completion of the training course, the Advanced
Clinical Nurses are registered to practice by the Medical
Council and are usually employed by the Ministry of Health.
These nurses will assist a medical practitioner in running a hospital or staffing rural and district hospitals where medical practitioners are only available for consultation.
Clinical nurse specialists are charged with the need to arrange suitable community medicine when working in iso- lated areas and hence cooperate with the community nurses, health educators, and health visitors to carry on preventive health programs ^"^^'^ This constitutes a step forward in the training of nurses in this African country, contributing to the development and recognition of nursing as a profession. 327
References
1 Ross, W.F. The advanced clinical nurse and the health
team. Central African Journal of Medicine , 1975^ 21, 243-5.
2 Snelgrone, F.W. A school to be proud of. International Nursing Review, 1974^ 21, 9-12.
3 Whitaker, B. Mpilo Central Hospital. International Journal of Nursing Studies, 1966j S, 53-5. CHAPTER 27
ALGERIA
Before independence, Algeria's medical and nursing
services had been organized and staffed by the French, most
of whom left the country after 1962. The seven years'
revolt, from 1956 to 1962, caused complete chaos in Algeria,
Hospitals and medical staff were attacked and medical sup-
plies and equipment destroyed. After the war the Algerians
were faced with the task of reorganizing health care ser-
vices throughout the country. Due to the war, the lack of
education for women and prejudice against nursing as an
occupation for women, nursing care was mainly by male nurses. 1^31=3^^57
The nationalization of private clinics took place
in 1965 and all persons with some medical or nursing expe-
rience were mobilized as volunteers to help in rural areas.
Efforts were also made to train nurses in the cities,
chiefly in basic skills, so they could assist in hospitals,
. o clinics, and dispensaries. 1 1
Along with local efforts that helped restore health
services, the Algerians had a number of French doctors who were sent by France as part of the French cooperation.
328 329
In addition, the Comite Chretian de Service en Algerie (CCSA)
established in 1962, took responsibility in coordinating the
aid given in the form of medical supplies by most of the
world's Protestant churches. Medical services, also provided
by this organization, involved the opening of clinics and
dispensaries and the training of paramedical workers who
later carried on the work previously done by the foreign
•'"'^^ medical staff .
Health Education Services
Paramedical centers provided three grades of training
(1) An eleven-month course trained students to become midwives, nursing aides, laboratory and x-ray technicians, and children's nursing assistants.
(2) A two-year program prepared male students to become nurses and laboratory assistants and female students to become midwives and assistants soaiale or social workers.
(3) A three-year curriculum prepared students to become sanitary inspectors and eventually to take charge of clinics and dispensaries in
. rural areas 1 : 32-3 ; 2 : 33-4
Since 1965 new hospitals have increasingly been built
in Algeria. Almost all the population now receives free
medical care through dispensaries, clinics, and hospitals
that constitute the unit of health service in different
districts of the country. Paramedical schools, administered by the Ministry of Health, train general nurses, pediatric nurses, rural midwives, physiotherapists, and dietitians. 330
Several of these centers are now available in Algeria.
Students qualifying for the programs become civil servants for they are confronted with an enormous job for which they
"^'^"^ "^"^ ^ ' dedicate their lives ' 331
References
1 Bull, M.R. Health services in Algeria: the formation of a new service for a new country, Nursing Mirror, 1969 128, 31-3.
2 Cowen, E. Algeria . . . public health in an emergent state. Nursing Mirror, 1913, 136, 33-5.
3 Stewart, I. and Austin, A. A history of nursing. New York: G.P. Putnam's Sons, 1962. CHAPTER 28
ETHIOPIA
The first medical or nursing personnel trained in
Ethiopia were known as dressers . Training programs, estab-
lished in 1948-1949, with the assistance of the World
Health Organization Field Mission, provided hospitals and
rural areas with personnel who had some kind of nursing
knowledge. Male students with limited schooling were the
only participants in the six-month courses. At the end of
the training period certificates were presented by the
Emperor himself in a graduation ceremony. Some of the more
capable students were encouraged after few years of clinical
experience to take another six-month course in nursing or
to take specialized courses in x-ray, laboratory technology,
"'""^^ ^ • pharmacy, or operating room techniques ' All
along, foreign nurses from different parts of the world
administered nursing care throughout the country.
Modern Nursing in Ethiopia
In 1949 the first nursing school was established by
the Red Cross Society in Addis Ababa with a Swedish nurse
in charge. Another school soon followed, known as the
Princess Zauditu Memorial School of Nursing, which was under 332 333
the auspices of the American Seventh-Day Adventist mission.
A school for male nurses was also opened at the Tafari
Nokonen Hospital. In 1951, the Princess Tsahais Memorial
Hospital and School of Nursing were established in memory
of the Princess Tsahais, daughter of the Emperor Haile
Selassie. The emperor and Empress were interested in nursing
and hospital work, possibly because their daughter showed
interest in the profession by seeking training in England
during World War II. However, on her return to Ethiopia
she died in childbirth. ^ •
The three-and-a-half to four-year program in the
schools mentioned above is under the supervision of the
Medical Education Board, established by the Ministry of
Health. Directors of the schools of nursing are members of
the Board and hence endeavor to standardize programs in
the schools, a step that contributed greatly to the develop-
^ "^^^ ^ ' ment of the nursing profession in Ethiopia . ' '
The Ethiopian Nurses' Association was admitted to
the International Council of Nurses in 1957. "^'^"^^ This and
other developments are promising indications that nursing has wisely combined features of different existing systems and adapted them to the needs of the people. 334
References
1 Goodman, M. Nursing and the WHO. American Journal of Nursing, 1949, 49, 134-6.
2 Magnussen, E. Nursing in Ethiopia. American Journal of Nursing, 1953, 5J, 296-7.
3 Stewart, I. and Austin, A. A history of nursing. New York: G.P. Putnam's Sons, 1962.
4 Wooldridge, R. Nursing in a famine. Nursing Times, 1976, 72(5), 166-7. PART VII
AUSTRALIA '
AUSTRALIA
Nursing in Australia goes back to 1838 when a group of Irish nuns arrived in New South Waives to found St. Vin-
cent's Hospital. They were followed in 1868 by the first trained nurses sent from England by Florence Nightingale to work in Sidney Hospital, established in 1788. Lucy Osburn, the Lady Superintendent, had the entire responsibility of
the nursing staff, composed mainly of nurses and wardsmen, and of the establishment of the training school for nurses. Women were engaged in the school as probationary nurses or
sisters while male nurses were constrained to male wards.
This plan met with opposition from the medical staff who disapproved of the employment of women as nurses and hence, gave them little support. However, this opposition, wore away with time to give way to the development of training schools ^ ' throughout the country .
Private nursing was the main field for some grad- uates, who shared living accommodations in nurses' clubs or cooperatives. However, in 1885 associations for district nurses were developed in most cities allowing nurses some freedom in arranging their work schedule . ^
336 337
Nursing Organizations
The first attempts at organization of the nursing
profession in Australia were made in 1898 by a group of New
South Wales nurses who decided to establish some sort of con-
trol of nursing and nurse training. This movement resulted
in the creation of the Australian Trained Nurses' Association
in 1899. It was followed two years later by formation of the
Victorian Trained Nurses' Association. Membership in these
organizations was required of all nurses seeking a nursing
post. The main objective of the nurses' associations was
establishment of a system for nurse registration in the whole
country. The Australasian Nursing Journal, started in 1903
as the official organ of the Australian Trained Nurses Asso-
ciation, became one of the world's oldest nursing journals.
This was followed by Una, a journal adopted by the Victorian
Trained Nurses ' Association.
Although efforts for State registration were made as
early as 1909, only in 1927 did all states come into line on
this. The Nurses' Ordinance, which operated in the Federal
territory, was passed in 1933. In addition to the Ordinance,
Nurses' and Midwives Acts were passed in each of the six
states of the Commonwealth, allowing a registered nurse in
one state to be eligible for admission to the Registers of
the other states. Registration was granted to nurses
trained in an approved school and examined by a recognized
c . 9 o body of examiners. 338
Each of the six states has its own professional
organization. However, the state organizations are loosely
knit into the Australian Nursing Federation which is affil-
iated with the International Council of Nurses. The Feder-
ation has helped to standardize the training of nurses through-
out Australia as well as the development of postgraduate nurs-
ing programs. The Federation now represents the whole organized
body of nurses throughout Australia and is the recognized
national ' association of all nurses in the country .
District Nursing
In 1909 an appeal was launched by the Countess of
Derby, wife of the Governor General of Australia, to found
a bush nursing service to supply nurses to the more isolated
areas of the country. This was met with great opposition by
doctors and nurses, and hence the service did not material-
ize. The Countess then turned to Amy Hughes, General Super- intendent of the Queen Victoria Jubilee Institute, to organ- ize an order of nurses in Australia similar to England's
Metropolitan District Nurses. Today, the Victorian Bush
Nursing Association has many Bush Nursing hospitals and nursing centers throughout the country. Hospitals that were once isolated in small communities have served the large towns that have grown around them ever since. Nursing prac- tices in these hospitals are patterned on the British system.
However, most Bush hospitals are established and controlled by the local communities. Apart from making medical decisions. 339
nurses in the Bush nursing centers carry a heavy responsibil-
ity, being at times miles away from the nearest physician or ^"^^'^ ^ ' a larger medical center .
Another voluntary organization that provided nursing
service for the hinterland and the nearby Pacific islands
was the Australian Inland Mission. Services of nurses in
this Mission are world known. An example is the work done
by Sister Elizabeth Kenny whose isolation in a doctorless
area led her to the discovery of a new method for the treat-
ment of poliomyelitis. The services of the flying doctors,
at present, tend to strengthen these nursing posts. Hospi-
tal planes and wireless stations make it possible for set-
tlers in remote areas to get free medical consultation and
'^ ' -^^"^^ the ^ " services ' of doctors and nurses needed .
Nursing Education
Through Australian history, the nurse has been seen
as a health worker requiring a different kind of education
from other members of the health team. The hospital-based
apprenticeship system persisted in nursing for a long time while other health workers developed different kinds of institutions. Since nurse training was in the form of an apprenticeship, the socialization of nursing students started with conformity to hospital regulations and organization.
Such a system that called for low entrance requirements and live-in emphasis provided the community with nursing service at a low cost. In addition, discipline is still emphasized 340
as a major yardstick in the training of nurses in Australia.
This is criticized by nurse professionals who see the situa-
tion hampering the development of the profession.
In spite of the fact that university nursing programs
developed in North America and other parts of the world, the
apprenticeship system of nurse training has survived in
England and Australia. In England for a long time, the tra-
ditional structure of the university refused to admit such
a specialized and practical department as a nursing school
to its campus. In order to hamper any further developments
in the profession, nursing education in Australia was exclu-
ded from tertiary institutions as well. This was attrib- uted to the inability of the profession then to describe its
own role in the health field. To better illustrate this,
the sociologist Hans Mauksch used the analogy of a flattened
sheet of biscuit dough in describing the inheritance of nurs-
ing. In his opinion, many new specialized personnel on the health team cut biscuits in terms of their specialized ser- vices to the patients. These people include technicians, therapists, social workers, and pharmacists who staked their claims in patient care, leaving nursing with pieces of dis- connected scraps of what was once the whole sheet of dough.
More biscuit cutting continues, which leaves the nursing pro- fession in the position of coordinating the pieces — the functions — in order to get the various services to the A-32-3 patient.
• '.1 341
Realizing the importance of upgrading nursing educa-
tion, nursing educators have recognized the need for a better
education for nurses. As a result, the College of Nursing in
Australia was established in 1950 with its first courses con-
ducted in Melbourne. Subsequently branches were established
in other parts of the country. The college offers full-time
postgraduate courses in nursing education, nursing adminis-
tration, hospital nursing and ward management, public health
nursing, operating room theatre nursing and management, and
intensive care nursing and management. The courses, varying
in length from 28 to 42 weeks, are offered to hospital nurse
4 • 34 graduates interested in a specialty area.
In 1974, a diploma nursing course was started at the
College of Nursing leading to State registration under the
general nurse category. This program will have wide implica-
tions in Australia, for it has the potential of changing the
apprenticeship system of nursing education.
The nursing organizations are struggling with govern-
ment authorities to improve the status of the nursing profes-
sion in their country. The Australian Trained Nurses' Asso-
ciation, known today as the Royal Australian Nursing Feder-
ation, with branches in all the states and mainland terri-
tories, is concerned with regulating the quality of nursing
practice and nursing education. Only hospitals that conformed
to the regulations set by the Association were recognized as nursing schools and their graduates were allowed to register 342
as trained nurses with the Association. This measure has
helped in protecting the trained nurses and the public
/ . T / against untrained personnel in the nursing field. '
Colleges of Advanced Nursing Education
In 1964, the report of the Committee on the Future
of Tertiary Education in Australia, known as the Martin
Report, emphasized the need for the future development and
diversification of tertiary education in the country. The
focus was on Colleges of Advanced Education that share the
same university status; however, emphasis is on a more prac-
tical than theoretical approach to education. This scheme
was supported by the Commonwealth governments that assisted
the states financially in their efforts to establish the dif-
ferent Colleges of Advanced Education. The Victoria Insti-
tute of Colleges Act, passed by the government in 1965, was
followed by the establishment of an Institute of Colleges in
Victoria. The newly funded Institute acts as a coordinating
agency with which individual Colleges of Advanced Education
• 9 7 may become affiliated.
The New South VJales Government, on the other hand,
devised its own legislation plan for Advanced Education, the
New South Wales Higher Education Act of 1969. The legisla-
tion provides for the establishment of a Board instead of an Institute whose responsibility lies in the promotion, encouragement, development, improvement, and maintenance of
Advanced Education Courses. In 1972 the Council of the 343
New South Wales College of Nursing decided the College should become a school of nursing within the paramedical college that comprised the colleges of Physiotherapy, Occupational
Therapy, Speech Therapy, and Postgraduate Nursing Educa-
6 2 8~ 9 tion. This change has marked a sharp distinction between the New South Wales Colleges of Nursing and the
College of Nursing, Australia, which is a single-purpose
College of Advanced Education. The Commonwealth appears to favor creation of larger multipurpose Colleges of Advanced
Education as is the case in the Institute of Paramedical studies.
Goals in Nursing Education
The changing pattern of health care needs and deliv- ery services, together with the rapid expansion in scientific knowledge, demands a change in the nursing education system.
The nursing profession was presumed to be unable to provide adequate services to meet community needs in Australia. The nursing profession, at present, believes nursing education should be phased into the general education system and the nursing programs placed at the tertiary diploma level. That graduates of these programs be competent and safe nursing practitioners is the concern expressed by the nursing leaders of the country, who represent the goals of nursing education '^"^^ in general.
Two categories of nursing personnel are presently functioning in Australia, the professional nurse and the 344
auxiliary nurse. The educational programs that prepare pro-
fessional nurses are conducted by the multidiscipline
education institutions at the tertiary diploma level, whereas
those that prepare auxiliary nurses are conducted by multi-
discipline education institutions at the subtertiary level.
The main goal is to establish basic nursing programs for
professional nurses that provide learning experiences with
students of other fields in the health professions. Such
programs are intended to contribute to the promotion of effec-
• 7 ' 12 tive functioning of the health team.
The development of postbasic programs in nursing is
a new trend in nursing education in Australia. These programs
are designed for professional nurses who are graduates of
either the hospital-based programs or programs conducted by
multidiscipline education institutions. Appropriate bridging
courses are made available to hospital graduates to help them
gain entry into the postgraduate diploma or degree programs.
Continuing education is also available to nurses employed
in hospitals and health agencies in an effort to keep them up
to date on new developments in the health field.
The Role of the Nurse in Australia
At present the nurse's role in Australia is accepted
as complementary to that of the physician. In addition to providing general physical care, the nurse is viewed as a healer, advisor, comforter, confidante, and technician. The nurse is accepted by the public as a person on the health team 345
who can advise on physical and mental health promotion,
prevention of disease, treatment, and rehabilitation. As a
primary health worker, the nurse is the first person the
patient contacts and consequently the proper delivery of
. ^"^ care in the health system depends on the nurse's judgement ^ '
Australian nurses function in many capacities. In
the hospital their activities vary from basic physical care
to complex technical procedures. In the nursing homes, acti-
vation and rehabilitation of the patient are their main con-
cerns. In the district nursing services, they focus on the
whole family. Nurses in child health centers are responsible
for routine physical examination and are actively engaged in
prevention of disease through the proper education of parents.
The bush nurses in most instances have to act without medical
assistance. Thus in some situations they have to take com-
plete responsibility for diagnosing, doing minor surgery,
deciding on drug administration, and handling obstetric
9-8-9' patients .
The community nurse or the public health nurse
fulfills an expanded version of the role of the nurse known elsewhere as the health visitor. This type of nurse came about as a result of need for a general nurse to support the general practitioner in medicine. The functions of a trained community nurse include:
(1) Provision of services to families at home or at a neighbouring center 346
(2) Nursing treatment at home
(3) Followup of patients referred from other centers
(4) Referral of problems to the general practitioner physician
(5) Mobilization and coordination of services
required by patients . 9 : 97-8
Centers for group practice constitute the primary
health facilities in Australia. A center is established close
to a health department that coordinates neighborhood programs.
The group practice employs a practice nurse, a receptionist
and secretarial help. The neighborhood health program util-
ises community nurses, a medical officer, and social workers.
The community nurse is the single point of contact between
general practitioner and patient, mobilizing curative and
preventive services. In her expanded role the nurse in
Australia acts as a bridge between patient and doctor. The
final responsibility of patient care, both legally and mor- ^ . ' ^^"^ ally, lies in the hands of the general practitioner
Health Services in Australia
Health services in Australia at the turn of the century were voluntary organizations supplemented by government sub-
sidies and patients' fees. With the emergence of new tech- niques, hospital equipment became more expensive leading to
an escalation in the cost of medical care. The government had to intervene accepting more responsibility in administer- ing and financing hospital services. In 1945 the Chifley government introduced free public hospital treatment, a scheme 347 achieved through agreements between the Commonwealth and the various State governments. The Commonwealth compensated the governments by paying six shillings a day for each occupied bed. Under the Hospital Benefits Act of 1951, the Menzies government approved a new agreement based on voluntary hospital insurance against costs of hospital treatment. The
Commonwealth government paid eight shillings a day for each occupied bed and additional payments were made to patients who were members of a registered hospital benefit organiza- tion. With the exception of the Queensland Labor government which refused to reintroduce charges for public hospital treatment, other States received 20 shillings subsidy per day until 1969, when sections of the health insurance act were implemented. '
Alterations in the financing of medical services are being debated. A universal health insurance scheme is proposed by the federal government, entitling all citizens to standard ward hospital treatment and coverage against medical expenses at no charge. Health care is introduced on the premise that it is a right and not merely a personal responsibility. The organized medical profession consti- tutes the principal base of opposition to this scheme.
Nurses, despite their numerical importance in the health care delivery system in Australia, have remained detached from the scene. ' This reluctance of nurses to become involved in controversial issues is attributed to their 348
acceptance of medical authority in the health field. If nursing is to grow as an independent profession, nurses must engage in debates on issues concerning their welfare and the welfare of the patient and the community. 349
References
1 Bell, J. Nursing conditions and problems in Australia. International Nursing Review, 1926j 1, 123-7.
2 Boorer, D. Nursing in Australia. Nursing TimeSj 1974, 70, 844-5.
3 Burbidge, G. Nursing in Australia. American Journal of Nursing, 1948, 48, 226-8.
4 Dickenson, M. and Law, G. Nurses in the national health scheme. The Lamp, 1976, 33(3), 30-6.
5 Evans, E.P. Nursing in Australia. International Nursing Review, 1938, 12, 260-4.
6 Parsons, R. Trends in nursing education in colleges of advanced education. The Lamp, 1975, 30(6), 6-32.
7 Royal Australian Nursing Federation. Goals in nursing education. Australian Nurses' Journal, 1976, 5(10), 11-4
8 Stewart, I. and Austin, A. A history of nursing. New York: G.P. Putnam's Sons, 1962.
9 White, R. The role of the nurse in Australia. Australia National Health and Medical Research Council, 1972.
10 Wyndham, O.H. Royal flying doctor service of Australia. International Journal of Nursing Studies, 1970, 7, 39-53. PART VIII
NEW ZEALAND NEW ZEALAND
The first nurses who trained under the Nightingale
system went to New Zealand in 1883 and helped inaugurate a
form of nurse training for upper middle class women. The
apprenticeship system was adopted and most nursing schools
were parts of public general hospitals. By 1889 schools of
nursing had been organized in three cities, Wellington, Auckland, and Chris tchurch , and soon their graduates intro-
duced this new system of nurse training into other parts of
the country. The school, hospital, and staff had to be
approved by the Nurses' and Midwives ' Registration Board and
were continuously inspected by the Department of Health.
Nursing and domestic services at the hospital and the train-
ing of nurses were the responsibility of the lady superin-
tendent of each hospital. As a result the matrons held a
strong position in the country and became the nursing leaders
. ^ in the large centers " ^ ^ • 264
The Nurses and Midwives Registration Board set out
regulations regarding nursing education which had little emphasis on theoretical instruction. The practical experi- ence of the students covered medical, surgical, and communi- cable disease nursing, pediatric nursing, operating room techniques, outpatient services, and dietetics. Obstetric 351 " '
352
nursing was never a basic course; it was offered at the post-
graduate level only. State examination was held at the end
of the first and third years of the three-year basic nursing
program. The final examination covered written as well as
practical nursing subjects. Nursing education in New Zealand
was free and student nurses received a monthly stipend in
^ return for their service in the general hospital .
Government Regulation
The Nurses' Registration Act, drafted by Grace Neill,
assistant inspector of hospitals, became law in 1901. The
Midwives Bill was passed in 1904 providing for the training
of midwives in state obstetrical hospitals. The training
took place in state-aided schools which v/ere under the direct
supervision of Grace Neill and later her successor, Hester
Mclean, who helped direct the national program for maternal
' and child health in New Zealand. ^ " ^^^^
In 1906 a nationwide voluntary organization was
started which greatly influenced the establishment of child health care in New Zealand. The Royal New Zealand Society
for the Health of Women and Children was formed to help sponsor Dr. Truby King's child care program. At present, this society is called the Plunket Society, after its
Patroness Lady Plunket, wife of the then Governor General. Local branches were soon developed in different parts of the country known as Karitane in which nurses taught mothers the care and feeding of their babies. Attracted by the Society's .
353
work, the government passed the Child Welfare Act in 1906,
marking the beginning of a broader responsibility in this 10:266 area
The Division of Hospitals and the Division of Nursing
were formed in the Health Department in 1920. The Division
of Hospitals fell under the direction of a medical practi-
tioner, whereas the Division of Nursing was the responsibil-
ity of a registered nurse and a midwife. The Nursing Divi-
sion was responsible for the supervision of training, exam-
ination, and registration of nurses, maternity nurses and
midwives ; the supervision of public hospitals and training
schools, and of district nursing services; and for the estab-
lishment of postgraduate courses in nursing. The Nurses and
Registration Act of 1925 governed the registration of nurses,
2 • 1 ?C)Q maternity nurses, and midwives.
Nursing Organizations
New Zealand had many private nurses' associations as
early as 1905. The first steps toward a national nursing
organization were taken by Hester Mclean when she called on
the separate associations to join together in one national
association. As a result, the New Zealand Trained Nurses'
Association, known now as the New Zealand Registered Nurses'
Association, came into being in 1909. In addition to regis-
tered nurses, midwives, maternity nurses and some physicians were among its active members. The Association became 354
a member of the International Council of Nurses in 1912.
Kai Tiaki became the Association's nursing journal in 1923 o o . 1 1 p and was edited by Hester Mclean, founder of the journal.
The New Zealand Registered Nurses' Association has
many branches scattered throughout the country. In addition
to a matron's section, two others are devoted to public health nursing and nursing education. An affiliated student nurses association, formed of the different councils repre-
senting the schools of nursing in the country, constitutes a section in the association. The student nurses' section of the main association was especially active in raising scholarships for study abroad.
Nursing Council of New Zealand
The Nursing Council of New Zealand was constituted under the Nurses' Act of 1971. The Council is responsible for the nursing education programs, examination, and regis- tration of nurses. The selection of curriculum content by the Council is based on the principle that all subject matter should be integrated and applied to the total nursing care of the patient. In addition, the Council undertakes the responsibility of conducting an ongoing evaluation program of all technical institutes and schools of nursing at all levels. One of the Council's main duties is the formation and maintenance of the Register, a challenge that the Council
. ' ^"^ has managed to handle ever since its development ^ 355
Nursing Education
Nursing education in New Zealand since its early days
had a tendency to follow the British system. This tie was
strengthened during World War II when many nurses from New
Zealand served in Britain and often remained for postbasic
education. Many British tutors were also attracted to New
Zealand and hence helped in introducing the British block
system of nursing education. Nursing textbooks and British
journals had an influence in strengthening the British 10:270 system.
Most nurses in New Zealand are prepared in Hospital
Board Schools of Nursing which are service based and hospital
oriented. As many as 139 basic nursing programs leading to
registration are offered by these schools. (See Table 2.)
The male nurse course is the same as the general nurse course
but with less emphasis on obstetric nursing. The psychopaedi
course prepared nurses to work with mentally retarded chil-
dren and the community nurse course is equivalent to the
9 • 20 practical nurse course in the United States.
The existence of separate courses at the basic level
stems from the historically separate administration of genera
and specialized hospitals. In 1972 responsibility for the maintenance of psychopaedic psychiatric, and midwifery ser- ,
vices was transferred from the Department of Health to Hospit
Boards, Separate administration has led to the development '
356
of different registration requirements, different curricula
and a different ^ career and salary s tructure .
Since the general nursing course does not offer
enough experience in maternity nursing, the majority of
registered nurses take the six-month postbasic course which
qualifies them as maternity nurses. A full 12-month midwifery
course at the postgraduate level came into being in 1930.
In addition, the Royal New Zealand Society for the Health of
Women and Children, or the Plunket Society, offers a four-
month course to registered nurses interested in working in
"'•^•^^ ^ ' ^ infant welfare and ' mothercraft agencies .
Also, in 1928, a six-month postgraduate course in
hospital and training school administration and public health
nursing was available to nurses interested in higher educa-
tion. This course was run by the Department of Health with the cooperation of Victoria University College, the Wellington Hospital public health services, and other social services in the country. 1=^3-6; 2: 1210
Students in Hospital Schools of Nursing in New Zealand are employees of the Hospital Boards. They work eight-hour shifts in a forty-hour work week. In the three-year general course, students receive a three-month introductory course during which they enjoy full student status. The remainder of the three years the block system is adopted during which students may have some 100 study days depending on the method adopted by the school. The Nursing Council in New Zealand 357
prescribes the minimum number of theoretical hours and the
content of the courses offered at the schools. Also the
clinical experience is planned and prescribed by the Council
which requires one month of training in a community health
center and one to three months in a psychiatric hospital.
Rostering students for service leaves little chance of corre-
lating theory with practice and thus the inevitable subordi- ^"^^ nation of education to service.
The nursing education system in New Zealand does not produce the kind of nurse that the country needs. The Divi-
sion of Nursing, Department of Health, New Zealand Nurses'
Association, and New Zealand Student Nurses' Association have done their best in pointing out the weaknesses of such a sys- tem. Also, the reports of the World Health Organization
Expert Committee on Nursing, and the Review of Hospitals and
Related Services have contributed to increasing government interest in nursing education and the need for change. The main goal behind the movement for change is the transfer of the education of nursing from the Department of Health to the
Department of Education. This places nursing education in the general education system and replaced the separate three- year programs with a single comperhensive basic course. ^'^"^
Since Hospital Boards form an important political force in the country, they managed to provide an obstacle to the removal of nursing schools from their realm of authority. They believe the maintenance of such schools in a hospital 358 setting ensures a continuous supply of trained nurses. This
belief was supported by the government that views the work
force that students represent in the hospital system as an 9-21-2 - important asset.
Change in Nursing Education
Basic courses in nursing education are in transition.
The Technical Institute programs embody the major themes of
the desired change that has been voiced through the past few
years. Such a program gives complete student status to the
participant, is not dominated by demands from hospital service,
and offers an equal share of theory and practice. Further-
more, such a program integrates family and community health
in its course structure, focusing more on the community than
on the hospital. All these programs are presently offered
outside the hospital boundaries, that is, within the Depart- ment of Education.
However, the School of Advanced Nursing Studies,
formerly known as the postgraduate school, is still under the Department of Health. The nine-month course covers sub-
jects in management of nursing service, nursing education, and public health nursing. Within the Department of Health two new programs have emerged lately: a regional course for qualified nurses in community health, offered at four tech- nical institutes, and a course for nurse tutors, offered at
Wellington ''•^ • and Hamilton Teachers' Colleges . Postbasic courses at the universities of Victoria and Massey are expanding in terms of programs and students. 359
The Victoria University offers courses in nursing studies to
be included in the Bachelor of Arts program. Massey Univer-
sity offers a diploma program in addition to the nursing
studies course. The course on nursing studies at Massey is
presently a part of the postgraduate area of study in nurs-
ing, offering both the Bachelor of Arts degrees (Honours)
and the Masterate degrees, Postbasic nursing programs have
continued to be offered at Massey University offering
refresher courses, mainly in clinical and technical subjects,
to nurses ^^"^^ throughout New Zealand. " (See Table 2.)
The basic nursing programs at the Nelson and
Wellington Polytechnics and the Christchurch and Auckland
Technical Institutes are progressing well. The Department
of Edcation Research and Planning Unit is responsible for the
ongoing evaluation of these programs. Graduate nurses of the
Technical Institutes are registered as comprehensive nurses
and are employed in a variety of settings in the health
services centers of the country. Private hospitals are
phasing out their hospital-based schools of nursing. However,
the country is left with 27 hospital schools offering three-
year general/male nursing courses, three-year psychiatric
nursing courses, three-year psychopaedic nursing courses,
eighteen-month community nurse courses, six-month maternity nursing courses, and six-month midwifery courses. Much atten- tion has been given lately to assisting these schools in im- proving the education and training of student nurses. ^"^^ . . .
360
TABLE 2
LEVELS OF NURSING EDUCATION IN NEW ZEALAND
Length Level Type of Course of Regis t ration Course
General Nurse 3 yrs . RGN
Male Nurse 3 yrs R Male N
Psychiatric Nurse 3 yrs RPN Basic Psychopaedic Nurse 3 yrs . R Psychopaedic Nurse
Community Nurse 18 mos RCN
Comprehensive Course 3 yrs . RN in Nursing
Midwifery 6 mos . RM
Management of 9 mos . Nursing Service Pos tbasic Nursing Education 9 mos .
Public Health 9 mos
Nursing Studies at Varies B.A. Degree Graduate Victoria and Massey Universities
Post- Nursing Studies at Varies Honours and graduate Massey University Masterate Degrees 361
Health Services in New Zealand
Two alternatives are available for operation of the
health care delivery system in New Zealand. One is known as
the medical model and the other as the health model. The dif-
ference between the two concepts, medical and health, is
related to the location of authority regarding decisions in
the health field. If the medical model is adopted, decisions
on health matters are concerned with medical and curative
matters. In such a case, nurses and other paramedical pro-
fessionals apply the medical decisions and their role is
mainly the intelligent execution of the required tasks.
Decisions of a medical type can be made by a nurse only in
the absence of a doctor, which means that the nurse will then
have acted ^ "^^^"^ ^-^ ^ outside her legitimate role . ' '
The health model takes a different base for authority
by involving patients, doctors, nurses, and other paramedicals
in the decision-making process. In this model, the emphasis
is on the synthesis of all decisions around and with the
patient. The responsibility and accountability of each health
professional are considered in terms of that person's area ^' of expertise. ^'"^'^
Responsibility for the nation's health lies in the hands of central and local government, private medical prac-
titioners, paramedical workers, charitable and religious organizations, and private citizens. The Central Government contributes to the country's health services by providing 362
encouragement, incentives, and financial assistance. The
Department of Health is responsible for the organization and
control of nursing services in general. These services
include the supervision of hospitals, homes for the aged,
and public health agencies. A great deal of delegation has
been moved to hospital boards where the chief nursing officer
is directly responsible to the chief medical officer in the
day-to-day execution of health services. "
Under the Social Security Act, medical practitioners
give prenatal, neonatal, and postnatal care. Free antenatal
clinics are established in maternity hospitals and wards as well as general hospitals throughout the country. Antenatal
mothers' classes prepare mothers for the arrival of their
babies. In New Zealand most of the confinements take place
in maternity hospitals or in maternity units of public hos- pitals. Health services in the maternity and child area are
the responsibility of the Department of Health, hospital boards, the medical and nursing professions, and the Royal
New Zealand Society for the Health of Women and Children,
(Plunket Society). In addition, the Department of Health provides a preventive child health service, physicians provid- ing the initial examination of infants and public health
^ nurses ^ • undertaking supervision and f ollowup .
Although the team approach to the provision of primary health services has been slow to develop in New Zealand, the role of the nurse in the primary health care is becoming 363
better defined. In 1970 the first subsidized practice nurse
scheme was introduced for rural doctors resulting in
increased utilization of practice nurses. A second subsi-
dized scheme was introduced in 1974 for doctors working in
rural and urban areas. This has led to an increase in the
employment of practice nurses in urban centers. The wide
range of nursing skills available in general practice, accord-
ing to a survey done in 1975, has contributed a great deal
to the improvement in the quality of health care provided.
Nurses were found to ease the work load of physicians, ena-
bling the latter to care for a larger number of patients.
Many medical and technical procedures, traditionally done by
doctors, are being delegated to the nurse. Undoubtedly this
aspect of nursing care will increase and extensive use of practice nurses and other members of the health team will become more acceptable by the population. A not uncommon experience is for a patient to ask to be seen by a nurse
. ' ^^"^ rather than by a doctor ^ 364
References
1 Boyd, E. Postbasic nursing education in New Zealand. International Nursing Review, 1910, 17, 43-52.
2 Bridges, E.R. Nursing in New Zealand. American Journal of Nursing, 1939, Z9, 1205-12.
3 Health and hospitals. New Zealand Official Yearbook, 1974, 5, 124-40.
4 Hordacq, C. Constraints and opportunities in a nursing career. International Nursing Review, 1973, 20, 112-3.
5 Nursing in New Zealand. American Journal of Nursing, 1947, 47, 216-7.
6 Penman, H.G. Health service reorganization. New Zealand Medical Journal, 1975, 82(543), 22-3.
7 Report of the Department of Health. The public health. New Zealand: Department of Health, 1976.
8 Report of the Nursing Council of New Zealand. The nursing council of New Zealand. New Zealand: Nursing Council, 1976.
9 Shadbolt, Y.T. Nursing education in New Zealand. The New Zealand Nursing Journal, 1975, 68(1), 19-22.
10 Stewart, I and Austin, A. A history of nursing. New York: G.P. Putnam's Sons, 1962.
11 Thomson, M. Change in nursing education. The New Zealand Nursing Journal, 1975, 68(12), 22-3. PART IX
NURSING IN THE FUTURE NURSING IN THE FUTURE
Nursing Practice
Over the past few years, many experiments on the
availability, quality, and scope of health care have taken
place. Such experiments dealt with the expanded role of
professionals in nursing and the different ways paraprofes-
sionals could be utilized. The movement toward expanding
the role of the nurse evolved recently, prompted by differ-
ent social forces such as consumer demands for higher quality
care and better distribution of health care facilities.
Also the nursing profession has witnessed an increased number
of nurses seeking advanced nursing education as clinical
specialists and nurse practitioners. This new movement led
nurses to rebel against the system and as a result adopt new
titles such as family nurse practitioners, pediatric nurse
practitioners, geriatric nurse practitioners, primary nurses,
direct care nurses, rural health practitioners, adult health
practitioners, medical nurse practitioners, and psychiatric
. . 1-22 nurse practitioners.
The shift in perspective from medical care to health
care is a recent trend. The health care concept places more
emphasis on prevention and health maintenance than did the medical care concept, which emphasized mainly treatment of
366
1 367
the sick. Nurses are gaining recognition throughout the world
as providers of primary health care. In the United States,
the question about direct reimbursement for nonphysician pro-
viders has been considered by Congress. The variety of
approaches for reimbursement include (1) nonprofit group
practices of nurses, (2) health maintenance organizations,
(3) rural and urban nurse clinics, and (4) home health nurs-
ing services. Nurses in the United States believe they have
the right to be recognized as providers of care, thus making
them eligible for direct reimbursement just as are dentists,
3 '• 11-12 optometrists, physicians podiatrists , and psychologists. ,
The role of nurse practitioner requires more than the
gaining of new skills in medicine and nursing; it requires
a complete reorientation of the nurse to a totally new career
that requires greater independence and responsibility. The
transition period will result in the modification of social
and professional norms, attitudes and values as an outcome
of the newly perceived role. These changes will be accom-
panied by a great deal of physical, social, and psychological
stress as nurses move from their traditional role to a role
that emphasizes nursing assessment and decision making.
Additional stresses include the development of a viable rela-
tion with medical coworkers who are at times misinformed of
the nurse practitioners' functions and who therefore feel ^"^"^^ threatened by this new type of health care worker 368
In order to reach a mutual understanding of the role and functions of a nurse practitioner, the American Medical Association and the American Nurses' Association have held a series of joint conferences. The National Joint Practice Commission was an outgrowth of these efforts. The commis- sion which includes eight physicians and eight nurses is currently working on a publication on innovations for joint practice. In addition to serving on the commission, physi- cians have served on committees to develop guidelines for nurse practitioner programs. Physicians have also assisted in writing test items for the certification examinations for pediatric nurse practitioners and family and adult nurse 2^-25 ' practitioners .
Nursing Education
The knowledge explosion coupled with rapidly growing technology will affect the way nursing will be taught in the future. Maximizing education for individuals will be the goal of the coming century. To be prepared for the more demanding future, nurses throughout the world will need to be aware of trends and developments in the field. Faced with such massive social concerns-not only the knowledge explo- sion but the energy crisis, resource depletion, world hunger, and overpopulation-many countries are turning to the com- puter for assistance. In Japan, for example, the individual model on which society is built is being replaced by the 369
information model. This newly planned society is known as
the information society. In such a society the computer will
undoubtedly play an important role in manipulating and stor-
ing the vast amount of data available in a far more orderly
fashion than human beings could do by conventional meth- ods.''^"-15
The classic role of the teacher as the primary
transmitter of knowledge is undoubtedly disappearing. New
and innovative teaching methods such as programmed instruc-
tion, learning modules, computer-based or computer-managed
instruction and various other strategies classified as indi-
vidualized instruction are becoming increasingly popular.
As a result, the teacher will become more of a facilitator
of learning, allowing technology to participate in the teach-
ing/learning process. In the future the use of the computer will be widespread in some parts of the world, helping the
teacher manage the increasingly complex educational environ- ment. Such an effort will include instruction, evaluation,
identification of problems, data gathering, data manipulation
for research, and continuing education. Some countries have already utilized the computer in some of these areas, whereas others are still experimenting.
The accelerated rate of change and its far-reaching implications for all institutions in society has always had its effect on the nursing profession. Nurses believe change is fundamental to the survival of the profession. A general .
370
agreement among nursing educators in the world is that reli-
able and relevant knowledge must be put to good use to meet
human needs. As a result, nursing faculty are continuously
engaged in improving their curricula by making changes to
affect the quality of the educational experiences students
receive. Such a trend is envisioned as vital to the profes-
sion only if new developments in nursing curricula are based
on a foxandation of validated knowledge. Nursing educators,
like other educators, should look critically at innovations
before adopting major curricular changes, especially at this
time when the profession is moving into full professional status
World Health and Nursing
After an examination of the various methods used by
countries throughout the world in providing health care,
a general conclusion can be drawn that in both developed
and developing countries the health care delivery system
does not meet the needs of the whole population. To remedy
this, the World Health Organization introduced the primary health care concept in 1975. Although such an approach differs from one country to another, the following general principles form a baseline:
(1) Primary health care is shaped around the life patterns of the population and hence meets the community's needs.
(2) Primary health care constitutes an integral part of the national health system. .
371
(3) Primary health care forms a part of the activ- ities involved in community development.
(4) Local communities are actively involved in the formulation and implementation of health care activities
(5) Health care provided places a reliance on avail- able resources in the community and falls within the financial limitations of the country.
(6) Primary health care integrates the concepts of prevention, promotion, cure, and rehabilitation in its effort to serve the individual, family, and community.
(7) Health services are provided at the practical level by personnel trained to form these activ-
ities . 2 : l64-5
In adopting these baseline principles to provide
primary health care at the community level throughout the
world, changes in the curricula and training of physicians,
nurses, and midwives should be introduced. This will enable
these health professionals to provide the health care ser-
vices the community needs. In addition, changes in training
programs of other health personnel, professional and para-
professional, will provide the team orientation concept,
helping the primary health workers become an integral part
of the communities they serve.
The providing of primary health care to every segment
of the population is today's most crucial health problem.
The training of members of the community as primary health
workers offers a realistic approach in providing health care
services to millions of people. The community health nurse will essentially assume more responsibilities in the training 372
of the primary health workers and in serving as a link
between them and the rest of the health care system.
To meet the growing needs for health care, nurses of
the future will be more community oriented. More community
nursing services will be developed that will provide primary
health coverage for every segment of the population. As a
result, nursing manpower will constitute a major part in the
health manpower scheme creating a challenge for nurses and
placing more responsibility on them in the health care deliv-
ery system.
Ethical Concepts in Nursing
Change is considered to be constant in today's society
which is always in a transient stage. Many honored institu-
tions in society, such as the family and church, have taken
different faces. Along with this movement, many ethical con-
cepts in nursing have changed, to be outgrown by the several
directions the profession is presently taking. Ethical codes,
at present, are drawn from real life situations, making use
of present and past experiences to look for the future.
Ethical concepts in the future might move from the
curative-preventive dichotomy to focus on the adaptation of
the individual to social change. Death will be looked at by nurses as an integral part of the life process and as a right of individuals to determine how they want to end their lives. The nurse will be called upon in the future to develop 373
innovative standards to meet the changing needs of society.
Competence through education and practice will be the future
yardstick. Togetherness rather than separation of roles is
the envisioned role that health workers might take to provide
the care needed by the patient. Each member of the health
team will contribute to the provision of health care in a holistic approach according to that person's area of special-
ization. Community involvement and consumer control of health
services will be the trend. Such a system will help bridge
the gap between the physician or other health worker and the patient. In addition, outreach services will be provided in an attempt to provide health services for the aged, the handi- capped, the battered child, the lay person in every nation.
These few thoughts on the future of nursing emphasize the personal responsibility for nursing practice, the commit- ment of the nurses to the welfare of society, and their sense of responsibility to speak up when an issue is at stake.
Nursing has witnessed great change but the future is more promising and presents a challenge to the nurses of the world. References
1 Apostoles, E. Role expansion in a psychiatric setting.
Nurse Practitioner , 1976, 2, 22-5.
2 Hentsch, Y. Community and world health. International Nursing Review, 1976, 23, 103-6.
3 Jennings, C. Third party reimbursement and the nurse practitioner. Nurse Practitioner, 1977, 2, 11-3.
4 Meadows, L. Nursing education in crisis, a computer alternative. Journal of Nursing Education, 1977, 16, 13-21. PART X
SUMMARY: NURSING FROM ANCIENT TO MODERN TIMES SUMMARY: NURSING FROM ANCIENT TO MODERN TIMES
Florence Nightingale's creation of St. Thomas'
Hospital School of Nursing in 1860 was the beginning of what is now known as modern nursing^ modern meaning the progress of nursing in the context of its marked phase of development and period of time. The contribution of
Florence Nightingale was the founding of a profession based on scientific innovation and medical knowledge. Thus, an independent self-supporting profession for women of educa- tion, culture, and social standing was founded on a secular, humanitarian, and strictly feminist basis.
General events and movements , shared by the different countries mentioned in this study, have had their impact on the development of the profession. The increasing num- ber of wars in recent centuries has led to increased partic- ipation of nurses in military service. Also, liberal, demo- cratic, social, and labor movements have placed a value on the health of the individual, family, and community, broad- ening the role of the nurse in this area. Colonial powers have also contributed to the establishment of nursing systems in some Asian and African countries. The Russian and Chinese revolutions have introduced ideologies that influenced the direction of nursing in some parts of the world.
376 377
Though modern nursing services were generally non- sectarian, religious orders that played an important role in establishing nursing schools through their mission work throughout the world have continued to administer and support hospitals and schools of nursing until the present. Nurse missionaries were sent to foreign countries carrying with them modern nursing systems of training. During the same period, social and civil agencies were developing, a move- ment that helped introduce the Nightingale nursing reforms to the already existing nursing systems of the countries.
Figure 7 shows the influence of the Nightingale system on the development of modem nursing practices in many countries.
The Red Cross movement has also had an influence on the profession. Red Cross, founded in 1864, concentrated on training nurses to serve in wars and natural disasters.
However, in times of peace, nurses were trained for private duty, visiting nursing, and hospital service. Red Cross schools of nursing throughout the world have attracted women from the upper middle and even higher social classes, thus raising the standards of the profession.
Noteworthy is the contribution of the World Health
Organization to the development of nursing in several coun- tries. This international organization through its dif- ferent offices has helped in organizing programs and, in some places, creating training centers for the preparation
of nurses in various specialties . The World Health 1 379
Organization also made material contributions to some
developing countries and some of these nations are still
dependent on this assitance.
Although primitive nursing was done mostly by the
servant class of society in most countries, many leaders
of the profession have come out of cultured homes to estab-
lish the roots of the modern nursing system. The develop-
ment of nursing as a profession seems to have gone hand in
hand with the international women's movement. The better
educational opportunities for girls, society's acceptance
of women seeking careers, and the availability of nursing
schools as an academic route have had an impact on attract-
ing young women of education and culture into the profession.
The dominant trend among all countries included in
this study has been toward the recognition of nursing as
a profession, distinct from other health professions. In
some countries nursing is an independent, self-supporting
profession, whereas in others it is still under medical
control. The professional development of nursing through-
out the world has been accompanied by the establishment of national associations leading to membership in the inter- national nursing organization. Also, nursing legislation for the control of nursing practice and education through registration of nurses and accreditation of nursing schools was another movement shared by nurses of the world. Table 3 shows how nursing associations have affected nursing 380
TABLE 3
NURSING REGISTRATION AND ORGANIZATION
Nursing Nursing ION Country Registration Associations Membership Australia 1927 1899 1937 Brazil 1931 1925 1929 Canada 1922 1899 1909
China 1937 ' 1909 1922 Egypt 1961 England 1889 1888 1900 Ethiopia 1957 France 1922 1923 1925 Germany 1905 1903 1904 Ghana 1946 1946 1961 Greece 1948 1923 1929 Holland 1921 1892 1928 India 1923 1905 1912 Ireland 1950 1925 1947 Israel 1953 1953 Italy 1954 1920 1946 Japan 1948 1925 1925 Lebanon 1932 1969
Mexico 1947J- -/ ^ / xy Q 1. New Zealand 1901 1908 1912 Nigeria 1910 1946 1961 Rhodesia 1949 Russia 1935 1938 South Africa 1891 1914 1922 Sweden 1920 1910 1929 Taiwan 1961 USA 1903 - 1923 1893 1900 Yugoslavia 1931 1926 1929 381
registration and International Council of Nurses membership
in most countries of the world, with the exception of
Nigeria, New Zealand and South Africa,
The education of nurses, professional and nonprofes-
sional, basic and advanced, has included similar trends and
movements. Schools of nursing in most countries are recog-
nized as separate institutions independent from the hospi-
tal system. Also nursing education at the basic level is
considered as a branch of professional work in some countries,
whereas in other it is still at the technical level. Many
countries have placed nursing education among other pro-
grams offered in higher educational institutions. The
establishment of university nursing programs at basic and
graduate levels is a worldwide trend. In some countries
university nursing education is the most common movement, whereas in others this constitutes a future goal. Table 4
lists the levels of educational practices in the countries
included in this study.
Fields of nursing service have multiplied rapidly during recent decades. Presently emphasis is on the con- cepts of prevention and positive health. With the expanded role of the nurse, conditions of practice have also improved giving nurses more responsibility in the health care delivery sys tem. Nursing personnel throughout the world are prepared at different levels to supplement the physician in providing primary health care. These primary health 382
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Table 5 shows the various titles these health workers have carried and compares their level of educational preparation in certain countries. Nursing conditions, including regulation of supply and demand, conditions of work, hours, salaries, and pen- sions, have improved in most countries. This is due in part to increased government involvement, and to the inter- est of professional and nursing organizations in matters that concern the future development of the profession. Also, nursing . journals and other communication channels have helped nurses interpret nursing to the public and have kept the profession abreast with new developments. Nursing surveys, studies, and research conducted in some countries have improved the quality of nursing care and contributed to the advancement of the profession at the international level. Nurses working across national boundaries have had a significant share in the development of their profession. They have shown the world they could rise above intoler- ance and inhumanity, fighting abuses but keeping their fraternal spirits and international aims. Broadening their knowledge about nursing practices in other countries ensures better cooperation and friendship among nurses of the world. This constitutes the best hope for nurses of the future and for a profession that is dedicated to the service of human- ity and world peace. 1 1 393 o a d •rl •H 0) o CO CO 4J •H nJ cO cd 4-» iH ,£1 J3 cC •H 4J U Ti o 0) CO CO :) o o T3 < PL, W T3 o o O <+-( 0) c d C U •H •H a O CO CO CO CO CO CO CO •H CO CO to i-( CJ o o O t-l O O o •H •H •H •H •U •H •H > W ca CO CO CO CO CO CO CO CO CO CO CO CO CO O 0 CO o CO 1-1 O pq P3 « < « CM PQ CM PQ CO QJ CM ON 00 O 00 o t— O <^ W 0) CO d o 01 •H CO C 4-1 CO QJ O •^^ CO QJ CO •H CO U U CJ -l Q a T) QJ d T3 iH u CO CJ CO CO CO :3 c o X C CO CO CO U !m -u o > Es; CO -H JJ CO QJ X) I-l u 13 CM o M N QJ QJ CO CM o 4-) O x; O QJ •H ^1 d CO 13 CO CO •r4 rH X) X) CO •r^ CO CO d d r-l •H 4J CO CO d ^ CO CO CO Q) U Q) •H QJ U CO r-4 C d r-l d CO QJ X) CO X) d CO d rH M CO U tJO O CO QJ <: o d CO d O u CO •r-( CJ d CO u < w X M M 2; BIBLIOGRAPHY Abdellah, F. Nursing and health care in the USSR. Amevican Journal of Nursing, 1973, 73, 2096-9. Abdellah, F. 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She then taught Maternal and Child Nursing for two years at the American University of Beirut School of Nursing. Because of her interest in higher education, the university granted financial support for graduate study at the Univer- sity of Florida, where she received a Master's degree in Pediatrics and Maternal and Infant Care Nursing in December 1975. . Memberships in professional organizations include Sigma Theta Tau, Phi Kappa Phi, and the Alumni Nurses' Chapter of the American University of Beirut. 419 I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and in quality, as a dissertation for the degree of Doctor of Philosophy. aU. Margar'e/t K. Morgan, 'Chairman Associate Professor of Curriculum and Instruction I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and in quality, as a dissertation for the degree of Doctor of Philosophy. Amanda S . Baker Associate Professor of Nursing I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and in quality, as a dissertation for the degree of Doctor of Philosophy. Gordon D. Lawrence Associate Professor of Curriculum and Instruction I certify that I have read this study and that in my opinion it conforms to .acceptable standards of scholarly presentation and is fully adequate, in scope and in quality, as a dissertation for the degree of Doctor of Philosophy. James W. Hens el Professor of Curriculum and Instruction I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate, in scope and in quality, as a dissertation for the degree of Doctor of Philosophy. Pauline H. Barton Professor of Nursing This dissertation was submitted to the Graduate Faculty of the College of Education and to the Graduate Council, and was accepted as partial fulfillment of the requirements for the degree of Doctor of Philosophy. August 19 77 Dean, College of Education Dean, Graduate School